Center Place Registration Form - Little Medical School

Registration Form

Little Doctor School Morning Camp at Center Place

Dates: June 17 - 21

Times: 9:00 AM - 12:00 PM

Grades: K - 5

Cost: $250.00

Student Information

Student Name(Required)

First Last

Date of Birth(Required)

Grade(Required)

Additional Participant/Sibling Information

Full Name

Date of Birth

Age

Grade

Emergency Contact(s)(Required)

Full Name

Relationship to Child

Phone Number

Allergies or Special Medical Considerations

Additional Information

Your Name(Required)

First Last

Relationship to Child(Required)

Phone(Required)

Email(Required)

The following individuals are authorized to pick up my child:(Required)

Checkout

Choose your program from the list below:(Required)

Please type in the number of participants you are registering for the program. (Required)

Price: $250.00

Coupon

Total

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Thank you!

We will be in touch soon with important information about this program. Please be aware, we require a minimum of 8 participants to hold this program. You will receive a full refund in the event we need to cancel. If you have any questions, please contact Kristina at (813) 863-1896 or kristina@littlemedicalschool.com.