Course Registration Form
Your Registration ID
Course Selected
Student's First Name
(Required)
Student's Last Name
(Required)
Student's Nickname
(Please leave blank, if none)
Primary Phone Number
(Required)
Street Address
City
State
ZIP
Student's E-Mail
8
9
10
11
12
Student's Grade
(Required)
Female
Male
Student's Sex
(Required)
Student's School
2024
2025
2026
2027
2028
2029
Graduation Year
(Required)
PSAT Score
The PSAT Score must be a valid numeric value
Dr.
Miss
Mr.
Mrs.
Ms.
Parent 1 Title
Parent 1 Full Name
Parent 1 E-Mail
(Required)
Parent 1 Work Phone
Phone number must include area code.
Parent 1 Home Phone
Phone number must include area code.
Parent 1 Cellphone
Phone number must include area code.
Dr.
Miss
Mr.
Mrs.
Ms.
Parent 2 Title
Parent 2 Full Name
Parent 2 E-Mail
Parent 2 Work Phone
Phone number must include area code.
Parent 2 Home Phone
Phone number must include area code.
Parent 2 Cellphone
Phone number must include area code.
My grandmother always said to say thank you. Would you mind telling me who referred you to my courses so that I may show my appreciation?
Comments
Must be exactly four digits.
4-Digit PIN
(Why do I need a PIN?)
Required
Refund Policy:
No refund will be issued after the course has begun.
I understand and accept the Refund Policy
Your data cannot be submitted because you did not select a COURSE to attend.
Your data cannot be submitted because you did not enter a LAST NAME.
Your data cannot be submitted because you did not enter a FIRST NAME.
Your data cannot be submitted because you did not enter a PRIMARY PHONE NUMBER.
Your data cannot be submitted because you did not select the student's GRADE.
Your data cannot be submitted because you did not enter the student's SEX.
Your data cannot be submitted because you did not enter the student's GRADUATION YEAR.
Your data cannot be submitted because you did not enter PARENT 1 e-mail address.
Your data cannot be submitted because you did not enter 4-digit PIN.
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