ASP Enrichment Sign Up Form

 

Please fully complete the following information and click the "Submit Form" button at the bottom of this page.

School/Organization: 

Contact Name: 

School Street Address: 

City: 

State:    Zip Code: 

Contact Title: 

School/Org. Phone: 

Contact Phone (if different): 

Contact Email: 

How did you hear about Mad Science? 

Scheduling Information

School Start Time:

School End Time: 

Estimated Enrollment: 

Preferred Season (First Choice):

Preferred Season (Second Choice):

Preferred day (First Choice): 

Preferred day (Second Choice): 

Dates of skip days (if any): 

Room Information

Preferred class start time:   
(No more than 15 minutes after end of school day)

Time room available for instructor setup:

Registration Information

Registration made through: 

Checks made payable to: 

Registration forms needed: 

Registration send home by school?  

Location parents will pickup children after class:

Notes/Comments: