Student Name
*
First Name
Last Name
Student's Date of Birth
*
-
Month
-
Day
Year
Date of Birth
Grade
*
Please Select
6
7
8
9
10
11
12
School
*
School District
*
Allergies
*
To make it easier for us to understand and accommodate your child(ren)'s needs, please add any additional Educational Information about your child below (i.e. ADHD, Dyslexia, etc.) We would like to ensure the safety and value of your child(ren)'s enjoyment at our Camps as much as possible. (Note: You may put "N/A", if applicable)
*
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.
Authorized Pickup
*
Mother (as mentioned above)
Father (as mentioned above)
Other
Relation to the child
*
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Mandatory Pickup/ Drop-Off Policies and Procedures
*
PAYMENT
Cancellable for future months
*
prev
next
( X )
Friday FUEL
Per month
$
80.00
for each
month
Email
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Enrollment & Payment Agreement
Please Read Carefully & Sign Below:
*
By signing below, i agree to the above Enrollment Agreement.
*
Date of Consent
*
-
Month
-
Day
Year
Date
How did you hear about us?
*
Please Select
Facebook
Email
Whatsapp
Friend
Representative called
Attended an event at GEM
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