Service & Payment Plan*

Summer Selection

Price

$200.00

Guardian First Name*

Guardian Last Name*

Guardian Email*

Guardian Phone Number*

Student First Name*

Student Last Name*

Student Email (Optional)

Student Phone Number (Optional)

Student Address*

Allergies/Medical Conditions*

Other pertinent info

Emergency Contact Name & Phone Number(s) (in the event guardian cannot be reached)*

I would like to purchase an additional number of Notes (billed separately)

Payment Information*

Payment amount:

$200.00

Total to pay:

$200.00