Class Registration Form

Please use this form to register for classes.

Choose a Class
Student's First Name
Student's Last Name
Street Address
City
State
Zip Code
Choose One
Date of Birth (mm/dd/yyyy)
Home Telephone Number
Grade (on September 1, 2008)
Name of School
Enter Parent/Guardian Information in the fields below
Parent/Guardian #1: Relationship to student
Parent/Guardian #1: First Name
Parent/Guardian #1: Last Name
Parent/Guardian #1: Home Phone
Parent/Guardian #1: Work Phone
Parent/Guardian #1: Cell Phone
Parent/Guardian #1: Email Address
Parent/Guardian #2: Relationship to student
Parent/Guardian #2: First Name
Parent/Guardian #2: Last Name
Parent/Guardian #2: Home Phone
Parent/Guardian #2: Work Phone
Parent/Guardian #2: Cell Phone
Parent/Guardian #2: Email Address
Emergency Contact Information
Emergency Contact #1: Name
Emergency Contact 31: Phone
Emergency Contact #2: Name
Emergency Contact #2: Phone
Names of persons, in addition to parents/guardians and emergency contacts listed above, to whom you authorize The Prime School of Mathematics to release your child
Medical Information
Medical Conditions / Allergies
Primary Physician's Name
Primary Physician's Phone
How did you learn about us?
If referred by a current student/parent, please enter their names.
Coupon or Discount Code
I understand and give my permission to TPSM that my child and/or his voice may appear in printed material, photographs, or visual and/or audio recordings from TPSM.
I have read The Prime School of Mathematic's Polices and Procedures and agree to adhere to them.
The information provided on this Registration Form is complete and accurate to the best of my knowledge.