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Riverside STEAM Center

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Riverside STEAM Center

Home
After-School
Camps
Join a Club!
Kids Night Out
Tutoring
Book a Tour
Contact Us

CONTACT US

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5225 Canyon Crest Drive, STE 303, Riverside, CA 92507
(951) 530-8188
tsc.riv@techsteamcenter.com

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Riverside STEAM Club

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Student Application

# of Children

1 child 2 children 3 children None

First Name *

Last Name *

Phone *

Birthday *

Gender *

Second Child

First Name *

Last Name *

Phone *

Birthday *

Gender *

Third Child

First Name *

Last Name *

Phone *

Birthday *

Gender *

Parent or Guardians Information

First Name *

Last Name *

Email Address *

Address *

City *

Desired Start Date *

Phone 1*

Phone 2 (optional)

Emergency Contacts

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Last Name *

Email Address *

Phone *

How did you hear about us? *

Relationship to the student *

Medical Information

Does this student have? Allergy *

Yes No None

Special Needs

Yes No None

Dietary Restrictions

Yes No None

Physical Restrictions

Yes No None

Notes

Time's up

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After-School Program in Riverside

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Student Application

# of Children

1 child 2 children 3 children None

First Name *

Last Name *

Phone *

Birthday *

Gender *

Second Child

First Name *

Last Name *

Phone *

Birthday *

Gender *

Third Child

First Name *

Last Name *

Phone *

Birthday *

Gender *

Parent or Guardians Information

First Name *

Last Name *

Email Address *

Address *

City *

Desired Start Date *

Phone 1*

Phone 2 (optional)

Emergency Contacts

First Name *

Last Name *

Email Address *

Phone *

How did you hear about us? *

Relationship to the student *

Medical Information

Does this student have? Allergy *

Yes No None

Special Needs

Yes No None

Dietary Restrictions

Yes No None

Physical Restrictions

Yes No None

Notes

Time's up