Student
Which of our locations will your student be attending?
*
West University - 2014 Bissonnet Street, Houston, TX 77005
Memorial - 9409 Katy Freeway, Houston, TX 77024
Pick a time for BUILD: K-1 Early Reading Intervention (Kindergarten - 1st Grade)
*
7:00 AM - 8:00 AM (Bissonnet Location)
9:00 PM - 10:00 AM (Memorial Location)
3:00 PM - 4:00 PM
4:00 PM - 5:00 PM
5:00 PM - 6:00 PM
Student Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
N/A
Current School
*
Address
*
Address
Street Address Line 2
City
Please Select
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Tennessee
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Washington
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State
Zip Code
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Parent/Guardian(s)
Name
*
First Name
Last Name
Email
*
Day Phone
*
Cell Phone
*
Name
First Name
Last Name
Email
Day Phone
Cell Phone
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Authorized Pick Ups
Name
Phone Number
Relationship
Name
Phone Number
Relationship
Name
Phone Number
Relationship
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Emergency
Physician Name
Phone Number
Address
State
Please Select
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OK
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Zip Code
Hospital Name
Phone Number
Address
State
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AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
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Allergies
Medication Allergies
Food Allergies
Other Allergies
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Checkout
Registration Details
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Registration/Enrollment Fee
$
500.00
Supply Fee
$
1,000.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
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