Early Release Day After School Registration

1
Student 1 Name* This field is required.
First Name
Last Name
2
Student 1 School Name* This field is required.
Please Select
Please Select
Koontz Elementary
Overton Elementary
North Rowan Elementary
Mt. Ulla Elementary
Millbridge Elementary
North Rowan Middle School
Shive Elementary
3
Grade Level of Student 1* This field is required.
Please Select
Please Select
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
4
Are you needing to sign up a 2nd Student?* This field is required.
YESNO
5
Name of Student 2
First Name
Last Name
6
Student 2 School Name
Please Select
Please Select
Koontz Elementary
Overton Elementary
North Rowan Elementary
Mt. Ulla Elementary
Millbridge Elementary
North Rowan Middle School
Shive Elementary
7
Grade Level of Student 2
Please Select
Please Select
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
8
Are you needing to sign up a 3rd Student?
YESNO
9
Name of Student 3
First Name
Last Name
10
Student 3 School Name
Please Select
Please Select
Koontz Elementary
Overton Elementary
North Rowan Elementary
Mt. Ulla Elementary
Millbridge Elementary
North Rowan Middle School
Shive Elementary
11
Grade Level of Student 3
Please Select
Please Select
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
12
Parent/Guardian Name* This field is required.
First Name
Last Name
13
Parent/Guardian Email* This field is required.
example@example.com
14
Parent/Guardian Phone Number* This field is required.
Please enter a valid phone number.
15
Emergency Contact Name* This field is required.
First Name
Last Name
16
Emergency Contact Phone Number* This field is required.
Please enter a valid phone number.
17
Please list individuals (first and last names) who would be eligible for pick up* This field is required.You may update this at any time throughout the school year.
Huge
Large
Normal
Small
Ok
Ok
18
Terms and Conditions* This field is required.
19
Registration Fee* This field is required.Please be sure to select your child(ren)’s school as your item. When a route is filled the item will no longer be able to be purchased. If your route is full please contact BrickEd to get on our waitlist at 704-603-4597. **Reminder registration fee is $20.00 per child.
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My Bag
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My Bag
Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
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ORDER SUMMARY
Total costUSD
Shive Elem, Koontz Elem Students
$20.00Edit
Back
1
1
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4
5
6
7
8
9
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11
12
13
Quantity
North Rowan Elementary, North Rowan Middle Students
$20.00Edit
Back
1
1
2
3
4
5
6
7
8
9
10
11
12
13
Quantity
Overton Elementary Students
$20.00Edit
Back
1
1
2
3
4
5
6
7
8
9
10
Quantity
Mt. Ulla Elem, Millbridge Elem Students
$20.00Edit
Back
1
1
2
3
4
5
6
7
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9
10
11
12
13
Quantity
Enter Coupon
Total cost $0.00
Credit Card
First Name
Last Name
Should be Empty: