Math Club Application Form - Laureates Academy for Gifted Students

REGISTRATION FORMS MUST BE COMPLETED ACCURATELY AND, IN THEIR ENTIRETY, TO ENSURE A SPOT IS RESERVED FOR YOUR CHILD. PLEASE ENSURE ALL SECTIONS ARE FILLED OUT FULLY BEFORE SUBMISSION TO AVOID REGISTRATION DELAYS.

Checkboxes

I AM A RETURNING STUDENT AND MY CONTACT INFO HAS NOT CHANGED (PLEASE FILL IN THE STUDENT FIRST NAME, LAST NAME, ENTRY GRADE, IEP, AND GENDER)
I AM A RETURNING STUDENT AND MY CONTACT INFO HAS CHANGED (PLEASE FILL OUT THE ENTIRE APPLICATION FORM)
I AM A NEW STUDENT (PLEASE FILL OUT THE ENTIRE APPLICATION FORM)

1. STUDENT INFORMATION

Name

First

Last

Grade

Date of Birth

Gender

Male
Female
Not Specified

2. PARENT/GUARDIAN INFORMATION

Primary Contact

Parent/Guardian 1
Parent/Guardian 2
Both

PARENT/GUARDIAN1:

Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Cell Phone Number

Home Phone Number

Email

Occupation

PARENT/GUARDIAN2:

Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Phone Number

Phone

Email

Occupation

3. SCHOOL INFORMATION

School Name

4. PAYMENT OPTIONS ($4,000 FOR 80 Classes Annually)

Package

One Payment Upon Registration ($200 discount)
Two Payments 3 Months Apart (No discount)