Middle School Pgm

Registration for Bullis Middle School Program

On-line Registration for Pass Academy at Bullis School

Pass Academy Middle School Program Registration Form for Winter 2023/24
Student's Name*
First Last
Parent Information
Parent's Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Parent's Email Address*
Enter Email Confirm Email
Parent's Phone*
Bullis Middle School Program
Nov. 20th - March 1st
Middle School Pgm
Price:
4 Days a Week*
- 2:15 - 3:30pm ($925) MSP
Total Fees
$0.00
Credit Card*
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Medical Authorization & Release
Student Name*
First Last
Student Condition*
- By checking this box it is understood that the student is in overall good physical health. If your child has a physical condition that may limit or restrict participation in certain activities, a physician’s note granting permission to participate in such activities must be presented prior to the first class session.
Date of Medical Authorization*
MM slash DD slash YYYY

By dating above, in an emergency, when I/we cannot be contacted, I/we hereby authorize the staff of the Pass Academy to take my/our child to the emergency room of the nearest hospital. I/we authorize that hospital and its medical staff to provide treatment deemed necessary for the well-being of my/our child.
Date of Parent Release*
MM slash DD slash YYYY

By dating above, I agree to hold the Pass Academy and Bullis School harmless for injury or loss that may occur as a result of my participation in Pass Academy activities.
Cancellation Policy*
- By checking this box I accept the following policy. Cancel prior to 1st class: pay for 1 class. Cancel after 1st class: pay for 1 class plus $75 replacement fee. Cancel after 2nd class: pay for 2 classes plus $100 replacement fee. Plus credit card fees. No refunds after 3rd week. Medical reasons will be accepted with a doctor’s note.
Additional Information (optional)

Registration for Bullis Middle School Program

On-line Registration for Pass Academy at Bullis School

Pass Academy Middle School Program Registration Form for Winter 2023/24

Parent Information

Bullis Middle School Program

Medical Authorization & Release