Registration Launch Session 2 MONDAY AUG 5 – FRIDAY AUG 9, 2024 1Student Info2Parent / Guardian Info3Mailing Address4Emergency Contacts5Payment Student InformationStudent First Name* Student Last Name* ESM Counselor (Name or N/A)* Student Phone Number*Student Email* Grade Entering*9th10th11th12thSchool* Shirt Size* Dietary Restrictions* Gender*MaleFemaleNonbinaryPrefer not to disclosePrefer to self-describeGender Identity* Parent / Guardian InformationParent / Guardian First Name* Parent / Guardian Last Name* Parent / Guardian Email* Parent / Guardian Phone Number* Mailing AddressStreet Address* Address Line 2 City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP / Postal Code* Emergency Contact InformationEmergency Contact Name* Emergency Contact Phone*Emergency Contact Relation to Student* Emergency Contact Name* Emergency Contact Phone*Emergency Contact Relation to Student* Payment InformationLaunch Day 1 - Registration FeeCredit Card*Card Details Cardholder Name Discount Code Total $0.00 NameThis field is for validation purposes and should be left unchanged.
