REGISTRATION FORM
Please Mail or Fax to 386-822-7502
     (Printable Registration Form)
   

 

Today's Date _____________

 

Child's Name__________________________________________ DOB ___/___/___

 

Grade (next fall) ______       M / F      School ______________________________

2nd Child's Name_________________________________________ DOB ___/___/___

 

Grade (next fall) ______       M / F       School _____________________________

 

Address___________________________________ City ______________ Zip _______

 

Day Phone (______)_________________      Night Phone (______)______________

 

Cell/ Pager (______)_________________    E-mail____________________________

 

If Possible, Please Group Me with the Following Friends:

 

1)____________________________________ , 2)__________________________________

        Fees
Week 1 Start Date: ______________________     $249
  Extended Care (Choose and Circle) AM ($30) PM ($40)  
         
Week 2 Start Date: ______________________     $249
  Extended Care (Choose and Circle) AM ($30) PM ($40)  
         
Week 3 Start Date: ______________________     $249
  Extended Care (Choose and Circle) AM ($30) PM ($40)  
         
Week 4 Start Date: ______________________     $249
  Extended Care (Choose and Circle) AM ($30) PM ($40)  
         
      Total  

Payment Method:

___ Check or Money Order

___ MasterCard

___ Visa

Card Number:_____________________________________

Expiration Date:_______________

Name as it Appears on Card:_________ญญญญญญ__________________

Security Code________________

Signature:_____________________________________________Amount to be Billed:$__________

 

SHIRT  SIZE YOUTH SIZES   SM   MED  LARGE  XL

The Volusia County School Board is not affiliated with the event in any manner, nor does it endorse or assume any responsibility for any activities, which may occur in connection with it.

 

Stetson University
Department of Continuing Education
Unit 8393
421 N. Woodland Blvd.
DeLand, Florida 32723 29.034476-81.302825

Phone Number : 386.822.7500
Fax Number : 386.822.7502

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