Registration Math Registration Form Student Information Student's Full Name Student's Grade Student's DOB Student's Gender MaleFemale Student's Address (optional) Does the student have any Allergies? If yes please list. (optional) Does the student have a medical condition? If yes please list. (optional) Does the student take any medication? If yes please list. (optional) Parent Information Parent Name Email Address Phone Emergency Contact (Full Name & Contact number) (optional) Where did you hear about our program? (optional) Choose a package: 1 Hour a week ($140) 2 Hours a week ($260) 3 Hours a week ($360) Subtotal $140.00 Processing fee $0.00 Total due $140.00 Please wait...
