Please fill all the required fields
Registering for:
*
2025-2026 Academic Year
2026 - 2027 Academic Year
1 - Student's Full Name
*
First Name
Last Name
Student Email
*
example@example.com
2 - Student's Date of Birth
*
-
Month
-
Day
Year
Date of Birth
3 - Grade Level (2026-2027)
*
Please Select
5
6
7
8
PARENT INFORMATION
Mother Full Name
*
First Name
Last Name
Mother Email
*
example@example.com
Mother Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Father Full Name
*
First Name
Last Name
Father Email
*
example@example.com
Father Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
PAYMENT
Save your child's spot
*
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Application Fee
Non Refundable
$
150.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Any Comments
Enrollment Agreement
Please review and sign
Signature
*
Date of Consent
*
/
Month
/
Day
Year
Date
How did you hear about this program
*
Facebook
Email
Whatsapp
Instagram
Friend
Back to School Fair
Representative called
Received postcard
GEM Newsletter
Other
Submit
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