Registration Form Please enable JavaScript in your browser to complete this form.Date *Parent's Name(s) *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Child's Name *FirstLastChild's Preferred NameBirthdate *Age as of September 1, 20223 Years Old4 Years OldOtherDays you would like to attend and tuition2 day class-Monday and Wednesday 12:30-3:15 2 day Class- Tuesday and Thursday 12:30-3:15 3 day Class-Tuesday, Wednesday and Thursday 9:00- 11:45 am 4 day Class-Monday, Tuesday, Wednesday , Thursday 12:30-3:15 pm *limited spotsOther I have met with Dirt Learning and I understand * the policies of play based child lead learning.I have scheduled a tour meetingName of Signee *Signature *Clear SignatureDate Payment InformationHow will you be paying? *Site via SquareVenmoPayment for Registration FeePay through Site: Returning Student - $ 85.00Pay through Site: New Student - $ 100.00Payments through site will go through Square. PaymentRegistration Returning Student paid thru Venmo - $85Registration New Student payment thru Venmo - $100Please send payments for venmo to the information listed. Venmo Name: @dirtlearning last 4 of phone number: 5227Who can we thank for letting you know about our program? SquareCardName on CardTotal$ 0.00Submit