First and Last Name
Age (if under 18 years old) Grade Level (if under 18)
Enrolling individually? (yes or no)
If not enrolling individually, is this a family or group enrollment?
Homeschooling? (yes or no)
If not homeschooling, provide name of school or program you are
currently enrolled in
(such as summer camp or organization):
School or Program City, State and Country:
Which course(s) are you enrolling for?
Why have you chosen this particular course(s)?
PARENT OR ADULT SUPERVISOR Name
Best Time of Day to Call You
Postal Mailing Address:
How did you hear about us?