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
*
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
*
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
Submit
Should be Empty: