Student Registration Form

Student Registration Form

Please fill out your details and review the registration fee agreement.
Student Full Name

First NameLast Name
Ages
Birthday

MonthDayYear
Parent/Guardian Full Name

First NameLast Name
Parent/Guardian Email Address
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contacts
Authorized Pickup Persons
Allergies/Medication
Insurance Waiver Statement: By signing this form, I agree that Purposeful Steps Learning Center, its staff, and volunteers are not liable for injuries that may occur during normal activities. I confirm my child is in good health and authorize emergency medical care if needed

Required fee for student registration

$15.00

Total