Program Registration Form


	Program Registration Form

Fill out all the fields below and hit the "Submit" button. Then mail in payment in full to:

Mad Science of Hawaii
PO Box 235324
Honolulu, HI 96823

Please fill out one form for EACH child. Completing this form does not guarantee your child a spot in the ASP you are requesting. Space is not guaranteed until payment has been received in full!

Child's Name:

Child's Birthday:

Child's Grade:

Health Concerns:

School/Location:

Is your child a student at this school?

Class Start Date:

Parent/Guardian Name:

Email:

Home Phone#:

Cell Phone#:

Mailing Address:

City/Zip:

Pickup Option:
My child will be picked up after class

My child will attend after-school care

My child will travel home by his/her own means

If picking up, please list ALL person/s authorized to pick up your child:

Payment Option:
Check (mail to: Mad Science)

Credit Card (Please fill out info below)

Credit Card: Visa Mastercard

Card #:

Expires:

Name on Card:

Thank you for enrolling in our After School Program! An email will be sent to you to confirm your registration once we have received your payment in full.