Holiday STEM Registration

Name *

First

Last

Date of Birth *//

Grade *

Name of School *

Name *

First

Last

Email *

Phone *

Emergency Contact *

First

Last

Relationship to Child *

Phone *

Medical Concerns *

Please list any medical concerns you may have for your child, including any/all allergies.

Payment Amount *

Cost per location is dependent on number of classes taught. Each class costs $12 at ALL locations.