Student Information

Student's Name *

Student's Name

First Name

Last Name

Student's Birthday *

Student's Birthday

YYYY

Student's Home Address *

Student's Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student's Email Address *

Student's Phone Number *

Student's Phone Number

(###)

###

####

Student's Current School

Student's Anticipated Grade Level at Time of Course *

Student's Anticipated Age at Time of Course *

Sex

Male

Female

Parent(s)/Guardian(s) Information

Parent(s)/Guardian(s) Name(s) *

Parent(s)/Guardian(s) Name(s)

First Name

Last Name

Parent(s)/Guardian(s) Address *

Parent(s)/Guardian(s) Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent(s)/Guardian(s) Email 1 *

Parent(s)/Guardian(s) Email 2

Parent(s)/Guardian(s) Home Phone *

Parent(s)/Guardian(s) Home Phone

(###)

###

####

Parent(s)/Guardian(s) Work Phone

(###)

###

####

Parent(s)/Guardian(s) Mobile Phone

(###)

###

####

Course Work Preference

Preferred Location *

Preferred Corse *

Specify the first Saturday you would like to begin: *

Specify the first Saturday you would like to begin:

YYYY