In-Person Program Registration

Select Location

Location

Program and Child Information

Program Name

Class Option

Student First Name

Student Last Name

Kid's Grade (Level in School)

Date of Birth

Gender

Additional Student

Add Another Child

Program Name

Class Option

Student First Name

Student Last Name

Kid's Grade (Level in School)

Date of Birth

Gender

Additional Student

Add Another Child

Program Name

Class Option

Student First Name

Student Last Name

Kid's Grade (Level in School)

Date of Birth

Gender

Parent Information

Parent's First Name

Parent's Last Name

Email

This email will be used to send monthly Invoices and Payment Receipts.

Alternate Email

Phone/Mobile

Alternate Phone

Address

Address Line 1

Address Line 2

City

State

Postal / Zip Code

Country

Additional Details

Media Consent

Yes

No

I consent that ULTIMATE CODERS may use photographs or videos of my child on their social media tools which includes but is not limited to their Facebook Page. I understand that these photos/videos will NOT be used for any other commercial purposes.

Do you authorize your child to sign him/her self in and out of ULTIMATE CODERS?

Yes

No

If any unauthorized person will try to pick-up your child, we will contact you at the numbers listed above. We will not leave your child with any unauthorized person without prior notice

How did you hear about us?

Your Feedback is valuable.

Describe - Other:

Friend / Relative Referral Name:

Additional Comments or Notes:

I have read and agree to the Terms and Conditions and Privacy Policy. If I do not cancel my monthly subscription within 48 hours before the first scheduled session, I will be responsible to pay monthly until I cancel or change my subscription.

In-Person Program Registration

Select Location

Program and Child Information

Parent Information

Additional Details

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