Fusion Programs Registration
ROBLOX Design & Coding! • March-April 2022

Student Information

Student Name
Gender
Birth Date
Home Address
Zip
Home Phone
Email Address
Parent 1 / Guardian
Work Phone
Cell Phone
Parent 2 / Guardian
Work Phone
Cell Phone
Emergency contact: (Name)
Relationship
Phone

Sibling Registration:

 

Student Information

Student Name
Gender
Birth Date
Home Address
Zip
Home Phone
Email Address
Parent 1 / Guardian
Work Phone
Cell Phone
Parent 2 / Guardian
Work Phone
Cell Phone
Emergency contact: (Name)
Relationship
Phone

Credit Card Information

Credit Card
CVV
Expiration Date
Postal Code

Register for the Fusion Program Below

Tuesday and Thursday  3:45pm – 5:15pm

I hereby enroll the child(red) named above and agree to ALL terms and conditions outlining the requirements of the FUSION ROBLOX Program. Enrollment is for the time specified.

  • Fusion Programs reserves the right to dismiss any student whose behavior is disruptive to the program. In such cases, there will be no refund.
  • I grant to Fusion Programs and to its employees the right to photograph my child and to use these photographs or video recordings for print or electronic publishing.
  • A fully completed medical form MUST be on file in the prior to the student’s first day. Both the parent section and the physician section must be completed. It will be provided to you upon registration.
  • No refunds for the program will be granted.

I have read the above statement, and the terms and conditions listed, and agree to all terms indicated.

By typing my name I agree to the above with my digital signature.