3rd Rock Kids Enrollment Form

3rd Rock Kids, Inc.

Member Registration Form
1st Parent Name

First NameLast Name
2nd Parent Name

First NameLast Name
Child's Name
Child Date of Birth
Email
example@example.com
Mailing Address (for mailing enrollment packages - no P.O. boxes)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Signature

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Enrollment Registration
$45.00 Quantity

Total

$0.00
Payment Methods

Choose from one of the PayPal options to make your payment.
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3rd Rock Kids, Inc.