Middle School Pgm

On-line Registration for Pass Academy at Bullis School

"*" indicates required fields

Pass Academy Middle School Program Registration Form for Winter 2025/26

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

November 10th 2025 - February 19th 2026

Middle School Pgm

Price:

MS Program*

2:15 - 3:30pm ($940) MSP

Total Fees

Credit Card*

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*

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*

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 2025/26

Parent Information

Bullis Middle School Program

Medical Authorization & Release