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Puruda Math Summer/2-SEMESTER Program Registration Form
MATHS
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* Indicates required question
Program Selection:
*
Summer Program
2 Semester Program
Student's Full Name
*
Your answer
Student's Date of Birth
*
MM
/
DD
/
YYYY
Student's Gender
*
Male
Female
Prefer not to say
Other
Course Selection
*
Prealgebra
Algebra 1
Geometry
Algebra 2 /Trignometry
Precalculus
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip code
*
Your answer
School Name
*
Your answer
Current grade (as of May)
*
Option 1
Name of First Parent
*
Your answer
Name of Second Parent
*
Your answer
Parents' Email
*
Your answer
First Parent's Phone Number
*
Your answer
Second Parent's Phone Number
*
Your answer
Name of referral (if applicable)
Your answer
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