Program Interest Form
Name
*
First Name
Last Name
Job Title / Position
*
Email
*
example@example.com
Phone Number
Format: (000) 000-0000.
School / Organization Name
*
Organization Type
*
Please Select
Elementary School
Middle School
High School
Recreation Center
NonProfit/ Community Organization
Summer Camp
Childcare / Youth Organization
Other
School / Organization Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which program(s) are you interested in?
*
Future Chefs Cooking
STEM World
Kid Fit 101
Digital Art
Grade Level
*
K - 2
3 - 5
6 - 8
9 - 12
Estimated Number of Students
When are you interested in starting?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Days
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
Preferred Program Time
*
Before School Programming
During School Programming
After School Programming
Weekend Programming
How often would you like the program offered?
*
Please Select
One -Time Program / Workshop
Weekly
Summer Program/ Camp
Special Event
Not Sure Yet
How would you prefer we contact you?
*
Phone
Email
Virtual Meeting
Submit
Should be Empty: