Registration Form - 2018/19 school year
Parents, please use this form to register your students for our programs.
Fill out a separate form for each child.
After you submit your registration you will be instructed on how to make the payment.
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
School *
Your answer
Current Grade *
Any allergies or health problems *
Your answer
Home address *
Your answer
Parent/Guardian First and Last name *
Your answer
Parent/Guardian contact Phone number *
Your answer
Parent/Guardian contact Email address *
Your answer
Emergency contact First and Last name *
Your answer
Emergency contact Phone number *
Your answer
How did you hear about us? *
Please be specific - if you were referred by a friend, please tell us their name. We have referral program for each friend you bring to our classes you will receive $30 gift card.
Your answer
Brain Gymnastics - group math classes
STEM classes
Advanced Math
Tutoring (individual classes)
Choose a preffered day(s) and we will get back to you with available times.
Parents please take time and read our polices. *
Required
Any message, special note or concerns
Your answer
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