Registration
Student Information
Student Name
*
First Name
Last Name
Student Age:
*
Grade
*
Please Select
6th Grade
7th Grade
8th Grade
School:
Allergies or Medical Conditions that we should be aware of?
Does your student have any accessibility needs?
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Registration
Parent/Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Relationship to Student
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Who is authorized to pick up your student each day?
Emergency Contact
Emergency Contact Name:
*
First Name
Last Name
Emergency Contact Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Student:
*
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Registration
Payment
Payment Options:
*
Pay $50 registration fee
Request scholarship (you will be contacted to notify of approval)
Registration Fee
*
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Registration Fee
$50.00
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Should be Empty: