Full S.T.E.A.M. Ahead Online Registration

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You will not be charged at the time of enrollment/registration. *After-School Program: Fees will be automatically processed every Friday before the upcoming week. No refunds for missed classes. Cancellation fees may apply.

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Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)*

Authorized for pick-up:*

Contact #1

Contact #1 First Name*

Last Name *

Type

How Can We Contact You?

Home Phone

Work #

Cell # Receive Text Message Notifications

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell # Receive Text Message Notifications

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School-age children only: School*

Grade Level*

Transportation Method*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

School:*

Ft. Myers: 1901 Brantley Rd. Unit 12, Ft. Myers, FL

Naples: 7070 Immokalee Rd, Naples, FL 34119 (@ St. Monica's Church)

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Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School-age children only: School*

Grade Level*

Transportation Method*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

School:*

Ft. Myers: 1901 Brantley Rd. Unit 12, Ft. Myers, FL

Naples: 7070 Immokalee Rd, Naples, FL 34119 (@ St. Monica's Church)

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School-age children only: School*

Grade Level*

Transportation Method*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

School:*

Ft. Myers: 1901 Brantley Rd. Unit 12, Ft. Myers, FL

Naples: 7070 Immokalee Rd, Naples, FL 34119 (@ St. Monica's Church)

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School-age children only: School*

Grade Level*

Transportation Method*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

School:*

Ft. Myers: 1901 Brantley Rd. Unit 12, Ft. Myers, FL

Naples: 7070 Immokalee Rd, Naples, FL 34119 (@ St. Monica's Church)

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

School-age children only: School*

Grade Level*

Transportation Method*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

School:*

Ft. Myers: 1901 Brantley Rd. Unit 12, Ft. Myers, FL

Naples: 7070 Immokalee Rd, Naples, FL 34119 (@ St. Monica's Church)

Enroll in Classes

Select Class

Add Another Student

Required Policies

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Questions or Concerns

Comments

Payment Information

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

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Student #3 (Show-Hide Details)

Additional Info

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Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

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Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

Required Policies

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