Register – Little Jammerz

Student Name*
First Last
Name of Elementary School*
Grade*
Teachers Name
Parent Name #1*
First Last
Parent #1 Cell Phone*
Parent #1 Home/Work Phone
Parent #1 Email*
Parent Name #2 (optional)
First Last
Parent #2 Phone (optional)
Parent #2 Email (optional)
Program Desired*
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
PICK UP INFORMATION

(fill out for after-school programs only)
Relation
Or I give my child permission to walk home
Name Of Pick up Person Two

(fill out for after-school programs only)
Relation
Total
$ 0.00 CAD
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Credit Card*
Credit Card Number & Expiry, CVC
Cardholder Name
Terms & Conditions*
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