Student Registration

Join our personalized STEM education program

Student Info

Parent Info

Academic Needs

Emergency Contact

Consent

Student Information

Please provide information about the student who will be participating in our programs.

Student First Name *

Student Last Name *

Student's Phone *

Student Email

Date of Birth *

Grade (4-12) *

School Name *

Please provide your contact information as the primary contact for your child.

Full Name *

Phone Number *

Email *

Address *

Tell us about your child's academic goals and tutoring needs.

Subject Need Tutoring *

Specific Goals *

Does the student have any learning difficulties or special needs?

Any additional comments or requests?

How did you hear about us?

Please provide an emergency contact who can be reached if you're unavailable.

Same as Parent Information

Emergency Contact Name *

Relationship to Student *

Emergency Contact Phone *

Emergency Contact Email

Emergency Contact Address

Please read and agree to our liability release terms before completing registration.