GEM Boys Lock-In
Friday, January 5th 9:00 PM - 6:30 AM
Student's Name
*
First Name
Last Name
Grade
*
Please Select
7
8
9
10
11
12
Student's Email
*
example@example.com
Student's Phone Number
*
Please enter a valid phone number.
Mother Name
*
First Name
Last Name
Mother Email
*
example@example.com
Mother Phone Number
*
Please enter a valid phone number.
Father Name
*
First Name
Last Name
Father Email
*
example@example.com
Father Phone Number
*
Please enter a valid phone number.
PAYMENT
*
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Youth Night Lock-in
Incl Breakfast
$
12.00
Dinner Box - Chinese
$8 after December 3
$
5.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Informed Consent & Acknowledgement
*
How did you hear about us?
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Facebook
Email
Website
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Friend
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