Registration Form
A. STUDENT INFORMATION
| Last Name | First Name | Middle | DOB mm/dd/yyyy | ||||
| Street Address | |||||||
| City or Town | State | Zip code | |||||
| Student Phone Contact | Student Email Address | ||||||
| ( ) | |||||||
| Grade | School Name | ||||||
B. PARENT/GUARDIAN INFORMATION
| Relationship to Student | First Name | Last Name | ||||
| Mailing Address (if different from Student) | ||||||
| City or Town | State | Zip code | ||||
| Phone Contact : | □ Home | ( ) | ||||
| □ Cell | ( ) | |||||
| □ Work | ( ) | |||||
I, ____________________________, affirm that all information above is true and complete to the
(Print Name)
best of my knowledge.
In the event the above information is proven false, NYEdupia can revoke enrollment of this participant.
X_______________________________________________ Date ______/______/______
Applicant (Parent/Guardian)
I accept[click] I DO NOT accept[click]
Online Payment
| Student’s Name: | ||||
| School Name: | ||||
| Class: | ||||
| Date of Birth: | ||||
| Address: | ||||
| Phone Number: | ||||
| Card Holder Name: | ||||
| Card Number: | ||||
| Expiration Date: | ||||
| CVV Number [Pop up (what’s this?)]: | ||||
| Billing Address: | House Number | Street | Apt | |
| City | State | Zip Code | ||
I accept [click] I do not accept[click]
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