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Student Registration
Student's First Name
Student's Last Name
Student's Birthday
*
required
Student's Gender
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Country
Healthcare Number
Doctor's Name
Doctor's Phone Number
Parent or Guardian's First and Last Name
Parent or Guardian's Cell Number
Parent or Guardian's Email Address
Parent or Guardian's Address (same as Student's?)
*
Required
Yes
No
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Country
Add another parent?
*
Required
Yes
No
Parent or Guardian (2) First and Last Name
Parent or Guardian (2) Cell
Parent or Guardian (2) Email Address
Parent or Guardian (2) Address (same as Student's?)
*
Required
Yes
No
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Country
Is your child immunized?
*
Yes
No
Does your child have any allergies, medical conditions, or require any medications?
Emergency Contact First and Last Name
Emergency Contact Phone Number
Emergency Contact Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Country
Emergency Contact's Relationship to student
Do you agree to a photo release?
*
Yes
No
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Choose a Program and Pay Structure
*
Summer Program - FLAT RATE - $150
Complete Registration
Thanks for registering!
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