Summer Enrichment

Parent/Guardian Information
Parent/Guardian's Name *

First Name Last Name
Select your relationship to the student(s): *

Father Mother Guardian
Place of Employment *
Primary Phone Number *
Secondary Phone Number *
E-mail *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Student(s) Information
How many students are you registering? *
(1) Student's Name *

First Name Last Name
Gender *
Student's Date of Birth *

- Month - Day Year
Fall Grade (i.e. 1st, 2nd, etc.) *
(2) Student's Name *

First Name Last Name
Gender *
Student's Date of Birth

- Month - Day Year
Fall Grade (i.e. 1st, 2nd, etc.) *
(3) Student's Name *

First Name Last Name
Gender *
Student's Date of Birth *

- Month - Day Year
Fall Grade (i.e. 1st, 2nd, etc.) *
(4) Student's Name *

First Name Last Name
Gender *
Student's Date of Birth *

- Month - Day Year
Fall Grade (i.e. 1st, 2nd, etc.) *
(5) Student's Name *

First Name Last Name
Gender *
Student's Date of Birth *

- Month - Day Year
Fall Grade (i.e. 1st, 2nd, etc.) *
Is the emergency contact different than the parent/guardian listed above?
Emergency Contact Information
Name *

First Name Last Name
Relationship to Student(s) *
Primary Phone Number *
Secondary Phone Number *
E-mail *

Payment *

Registration Fee ($25/Child) $ 25.00

Quantity

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

If you would like to pay for the weekly or daily fees now, please click here.
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