PA Summer Kickstart 2025

Date

MonthDayYear
Date
Summer Kickstart Registration
Student Address*

Street Address

Street Address Line 2

CityState

Zip Code
Number of Students*
- Student Name*
  
  First NameLast Name
- Preferred Name
- Birth Date*
  
  MonthDayYear
- Gender*
- Current School*
- School District
- Grade Fall 2025*
- YesNo
- AsianBlack or African AmericanWhiteAmerican Indian or Alaska NativeOtherNative Hawaiian or Other Pacific Islander
- Allergies
- Medications
- Are you interested in Fall Registration at Phoenix Academy*
- YES - You MAY use my child's picture.NO - I would rather you DID NOT use my child's picture.
- YES - My child MAY read to the therapy dog at Phoenix Academy.NO - My child MAY NOT read to the therapy dog at Phoenix Academy.
- Student Name*
  
  First NameLast Name
- Preferred Name
- Birth Date*
  
  MonthDayYear
- Gender*
- Current School*
- School District
- Grade Fall 2025*
- YesNo
- AsianBlack or African AmericanWhiteAmerican Indian or Alaska NativeOtherNative Hawaiian or Other Pacific Islander
- Allergies
- Medications
- Are you interested in Fall Registration at Phoenix Academy*
- YES - You MAY use my child's picture.NO - I would rather you did use my child's picture.
- YES - My child MAY read to the therapy dog at Phoenix Academy.NO - My child MAY NOT read to the therapy dog at Phoenix Academy.
- Student Name*
  
  First NameLast Name
- Preferred Name
- Birth Date*
  
  MonthDayYear
- Gender*
- Current School*
- School District
- Grade Fall 2025*
- YesNo
- AsianBlack or African AmericanWhiteAmerican Indian or Alaska NativeOtherNative Hawaiian or Other Pacific Islander
- Allergies
- Medications
- Are you interested in Fall Registration at Phoenix Academy*
- YES - You MAY use my child's picture.NO - I would rather you did use my child's picture.
- YES - My child MAY read to the therapy dog at Phoenix Academy.NO - My child MAY NOT read to the therapy dog at Phoenix Academy.
- Student Name*
  
  First NameLast Name
- Preferred Name
- Birth Date*
  
  MonthDayYear
- Gender*
- Current School*
- School District
- Grade Fall 2025*
- YesNo
- AsianBlack or African AmericanWhiteAmerican Indian or Alaska NativeOtherNative Hawaiian or Other Pacific Islander
- Allergies
- Medications
- Are you interested in Fall Registration at Phoenix Academy*
- YES - You MAY use my child's picture.NO - I would rather you did use my child's picture.
- Student Contact Information
- Full Name*
  
  First NameLast Name
- Relationship*
- Email*
- Primary Phone Number*
  Format: 000-000-0000.
- Primary Phone Type*
- Alternate Phone Number
  Format: 000-000-0000.
- Alternate Phone Type
- Address (if different than child)
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Full Name
  
  First NameLast Name
- Relationship
- Email
- Primary Phone Number
  Format: 000-000-0000.
- Primary Phone Type
- Alternate Phone Number
  Format: 000-000-0000.
- Alternate Phone Type
- Address (if different than child)
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Emergency Contact*
  
  First NameLast Name
- Relationship*
- Phone Number*
  Format: 000-000-0000.
- Phone Type*
- Email
  example@example.com
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Comments or Questions
- Registration Fee
- Are you interested in Financial Aid?
- What prompted you to register for Summer Kickstart?*
- Tuition
  
  Please complete your registration by submitting the $100 per student registration fee or $750 per student tuition payment to Phoenix Academy.
  
  All tuition balances are due on or before July 7th, 2025.
- Credit Card/PayPalCheck
- Tuition
- Registration Fee/Tuition Payment
  
  prevnext( X )
  USDTuition
- Pay by Check
  Please make your check for the registration fee or tuition payment payable to "Phoenix Academy" and send it to: Phoenix Academy - 1110 N 66th Street - Omaha, Nebraska 68132 - Registration is not complete until we receive the registration fee or tuition payment.
- Payment Methods
  
  Choose from one of the PayPal options to make your payment.
- Should be Empty:

Summer Kickstart Registration