Program Registration Form

Are you registering more than one child?

Child Name *

First Name Last Name

Child 2 Name

First Name Last Name

Child 3 Name

First Name Last Name

Grade *

Child 2 Grade

Child 3 Grade

Parent Name *

First Name Last Name

Parent Cell Phone *

Area Code Phone Number

If registering for Chess, does your child know how the pieces move?:

Yes No

If registering for Chess, does your child 2 know how the pieces move?:

Yes No

If registering for Chess, does your child 3 know how the pieces move?:

Yes No

If registering for Minecraft, your child's Minecraft name:

Required to whitelist your child into our server.

If registering for Minecraft, your child 2 Minecraft name:

Required to whitelist your child into our server.

If registering for Minecraft, your child 3 Minecraft name:

Required to whitelist your child into our server.

Email (this email will be used to notify you re connecting via Zoom) *

example@example.com

Special Note

Payment Information *

December Mini Camp

December Mini Camps	Quantity	Price
Chess Mini Camp		$ 50.00
Minecraft Mini Camp		$ 50.00

Item subtotal: $ 0.00

Chess Team

Winter Chess Team	Quantity	Price
Chess Team		$ 175.00

Item subtotal: $ 0.00

January Courses $ 65.00

January	Quantity
January Chess
January Minecraft SECTION 1 (Java only)
January Minecraft SECTION 2 (Devices and Windows 10)

February Courses $ 65.00

February	Quantity
February Chess
February Minecraft SECTION 1 (Java only)
January Minecraft SECTION 2 (Devices and Windows 10)

March Courses $ 65.00

March	Quantity
March Chess
March Minecraft SECTION 1 (Java only)
March Minecraft SECTION 2 (Devices and Windows 10)

Enter coupon

Total $ 0.00

Credit Card Information (we accept Visa, MasterCard, Discover, and Amex)
First Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Programs Registration