Enroll a Student | STEM Velocity

You are Enrolling One Student in...

Note: Fields marked with a star (*) are required.

Student Enrolling in Workshop
Student Name *
Student Gender *	Girl Boy
Date of Birth *
Grade Level *	If enrolling in a Summer Camp, please select the rising grade level.
Name of School *	If enrolling in a Summer Camp, please enter the school attending in the Fall.
Classroom/Teacher
Accommodations	e.g. allergies, food sensitivities, behavioral needs, learning techniques, transitioning time, proximity to facilitator, etc...
Parent/Guardian Information You must be a Parent or Legal guardian permitted to make decisions for the student indicated above.
First Name *
Last Name *
Address *
Home Phone *
Mobile Phone
Work Phone
E-mail *
	Please add me to your mailing list.
Emergency Contact
Full Name *
Relationship to Student
Phone *
Special Instructions Communication preferences, modified pickup times, other persons authorized to collect your student, etc...


Coupon Code
How did you hear about us?	e.g. Search Engine, Referral, Brochure, etc...

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