Please fill all the required fields
Registering for:
*
Speech & Debate Program - Fall 2025
1 - Student's Full Name
*
First Name
Last Name
Student's Email
*
example@example.com
2 - Student's Date of Birth
*
-
Month
-
Day
Year
Date of Birth
3 - Grade Level (2025-2026)
*
Please Select
5
6
7
8
PARENT INFORMATION
Mother Full Name
*
First Name
Last Name
Mother Email
*
example@example.com
Mother Phone Number
*
Please enter a valid phone number.
Father Full Name
*
First Name
Last Name
Father Email
*
example@example.com
Father Phone Number
*
Please enter a valid phone number.
Home Address
*
Street Address
Street Address Line 2
City
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State
Zip Code
PAYMENT
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Resource Fee
$
50.00
Speech & Debate Program- Fall 2025
10 Weeks
$
149.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Any Comments
Enrollment Agreement
Please review and sign
Signature
*
Date of Consent
*
/
Month
/
Day
Year
Date
How did you hear about this program
*
Facebook
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Back to School Fair
Representative called
Received postcard
GEM Newsletter
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