Charter School Materials and Service Purchase Form

Charter School Certificate Purchase

Dolphin STEM Academy
Student Information
Name *

First Name Last Name
Birth Date *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Country *
Last Grade Level Completed *
Anticipated start date *
Student's STEM area(s) of interest *
Additional comments/info about the student
Additional Purchase

Purchase for an additional student.
Do you want to make an additional purchase?

Yes, I want to purchase for an additional student. No, I do not want to purchase for an additional student.
Student Information

Purchase for an additional student.
Name

First Name Last Name
Birth Date

Month Day Year
Last Grade Level Completed
Anticipated start date
Student's STEM area(s) of interest
Additional comments/info about the student
Additional Purchase

Purchase for an additional student
Do you want to purchase for an additional student?

Yes, I want to purchase for an additional student. No, I do not want to purchase for an additional student.
Student Information

Purchase for an additional student.
Name

First Name Last Name
Birth Date

Month Day Year
Last Grade Level Completed
Anticipated start date
Student's STEM area(s) of interest
Additional comments/info about the student
Parent/Guardian Info
We don't spam and we don't sell info! We use contact information to get in touch with you about your requested service and programs at Dolphin STEM Academy.
Parent/Guardian Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Country *
Email *
Enter the email address to receive login information.
Phone Number *

Area Code Phone Number
How did you hear about Dolphin STEM Academy? *

Dolpin STEM Facebook Ad Dolphin STEM website Jen Mackinnon, Google Ad Other/Referral (Please enter referral name below)
Registration

Payment in Full Option
CHARTER SCHOOL VOUCHER PAYMENT

Please select your product or service below. You will not be charged on this form; instead, an invoice will be sent for payment using your charter school voucher/certficate.

Registration and Payment:

1 Independent Study Homeschool Course $ 129.99

Quantity

Independent Study Homeschool PACKAGE of 5 COURSES $ 499.00

Quantity

1 Teacher-supported Course $ 499.00

Teacher-supported Package of 5 Courses $ 1,499.00

Total # of STUDENT ENROLLMENTS
Item subtotal: $ 0.00

Tutoring session online, 90 minutes $ 60.00

Quantity

Tutoring session online, 90 minutes every week, per month $ 200.00

Quantity

Tutoring session online, 90 minutes 2 times per week, per month 2 $ 380.00

Quantity

Online STEM Clubs, October - April $ 99.00

Quantity

Enter coupon

Total $ 0.00

Submission of Application

Confirm your acceptance and agreement with our school policies.
CURRICULUM POLICY

An enrollment advisor will contact you to discuss our extensive list of courses and provide an orientation to the program. Courses are available between August and May of the school year. Please contact us with any questions.
AGREEEMENT

By signing and submitting this form, you acknowledge that you are an adult age 18 years or older and are completing this form on behalf of a child/minor in your care to participate in our curriculum program(s)/services. You agree to pay the required course fees for this program/service. Furthermore, you agree to the Terms of Service.
Signature *

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Name of adult who completed and signed this form *

First Name Last Name
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Charter School Certificate Purchase

Student Information

Additional Purchase

Student Information

Additional Purchase

Student Information

Parent/Guardian Info

Registration

Submission of Application