Spring Registration Form – Heartland Estate

Tell us about your teenager

Name of youth attending class *

First

Last

Date of Birth *

Age of teen as of January 2023 *

Gender *

Male
Female

Name of School

(If applicable)

How did you hear about FLOW? *

Social media, friend, advertisement, other

Parent/Guardian Information

Parent Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Payment information *

1 of 3 payments - $199.00
2 of three payments - $399.00
pay in full (save $50) - $550.00

**If your teenager is a returning student, you will receive a $100 discount as a thank you

Emergency Contact

Name *

First

Last

Relationship to youth *

Cell Phone Number *

Does student have a prescribed an inhaler or required medicine? If yes, please explain any instructions.

Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is there any additional information we should know about your student to ensure a positive experience?

Informed Consent and Acknowledgement

Medical Release and Authorization

Disclaimer - Covid-19

Confirmation

Signature *

Total amount due

$0.00

Payment *

Refund Policy

Refund policy for FLOW ___ Full refund if a written request to withdraw student is received within 7 days of the first day of class. After March 26, refund requests will be considered depending on specific situation. $50 non-refundable

Future Leaders Of the World Spring Registration

Tell us about your teenager

Parent/Guardian Information

Emergency Contact