After School Program Request Form 

Please use this form to indicate your program preferences. Once we receive your request, we will contact you to confirm.

Contact Mad Science for more information at mail@madsciencesd.com or call (858) 300-2481.


CUSTOMER INFORMATION

School or Organization:
Address:
Contact Name:
Position:

CONTACT INFORMATION

It is important that we are able to contact you if we have any questions. Please provide a phone number and the best time to contact you.

Day Phone:
Cell Phone:
Best Time To Call:
Email:
Best Method Of Contact:


AFTER SCHOOL PROGRAM INFORMATION

Day of the Week:
School Dismissal Time:
Number of Weeks:
Requested Start Date:

Additional scheduling details:

 

  

This form is to request an after school program. Clicking on the submit button will transfer your request to
Mad Science of San Diego