Parent Name *

First Name

Last Name

Parent Phone *

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Name *

First Name

Last Name

Student Grade Level *

6th

7th

8th

9th

10th

11th

12th

Please select the class times that your student is available: *

Sundays 10:00am-11:30am

Mondays 7:00pm-8:30pm

Tuesdays 7:00pm-8:30pm

Wednesdays 7:00pm-8:30pm

Thursdays 7:00pm-8:30pm

Medical and Emergency Care Disclaimer *

Event staff will not administer medication or provide health care to participants. In the event of an emergency, 911 will be called, and the emergency contacts listed on this form will be notified. It is the parent/guardian’s responsibility to ensure accurate contact information is provided.

I have read and understand the above.

Payment Terms *

By checking this box, I understand the program cost is $299/month ($897 total per student for the Season). I acknowledge and agree that payment is due upon receipt of the invoice. I understand that failure to make payment within 30 days of the invoice date may result in additional late fees. I accept full responsibility for ensuring timely payment, including any fees incurred for late payments.

I agree to the payment terms and conditions.

Program Consent and Permission *

The Keenan Innovators Program will take place over 12 weeks. By signing this form, I grant permission for my child to participate in the program, work with Keenan staff, and use Keenan Center equipment for project completion.

I understand and agree.

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

How did you hear about the Keenan Innovators Program?

Radio

Social Media

Search Engine

Flyer

School/Guidance Counselor

Referral

Other