Please enable JavaScript in your browser to complete this form.Student Name *Date of Birth *Primary Parent Contact Name *Primary Parent Contact Email *Primary Parent Contact Emergency Number *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSchool Student Attends *Who besides the primary parent is authorized to pick up this student?About the StudentAllergiesMedical ConditionsLearning Challenges that impact classroom behavior and/or performanceMedicationsNote: We will not be able to administer medication during electivesAnything else that we need to know about this student?Option to pay Half Now / Half LaterCheck here to only pay half now and the remaining 50% by January 13th. A $10 processing fee applies.Student Grade/AgePre-K (Ages 4-5)Kindergarten - 2nd Grade3rd - 5th Grade6th - 8th GradeFor how many classes do you want to register this student?1234For how many classes do you want to register this student?123Select ClassGetting Ready for Kindergarten - $350.00Reminder: Payment below is for 50% of total payment due. We will bill you for the remaining half, which will be due by January 13th.There are currently no classes available for this age/grade.Total Due$0.00Upon submission of this form, you will be redirected to PayPal to securely process your registration fee payable to Intentional Education. After payment, you can return to this form and submit again if you need to register another student.Submit