Algebra Program Participation Agreement
Please complete this form to register and agree to the terms for participation in our Algebra Program.
Participant's Full Name
*
First Name
Last Name
Participant's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Participant's Email Address
*
example@example.com
Participant's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current School Name
*
Grade Level
*
Please Select
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Parent/Guardian Full Name (if participant is under 18)
First Name
Last Name
Parent/Guardian Email Address
example@example.com
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Select Algebra Program Session
*
Please Select
Beginner Algebra (Mondays 4-6pm)
Intermediate Algebra (Wednesdays 4-6pm)
Advanced Algebra (Fridays 4-6pm)
Other
Please list any allergies or medical conditions we should be aware of
Participant or Parent/Guardian Signature
*
Submit Agreement
Submit Agreement
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