*Name of Child

*Date of Birth

*Gender
FemaleMale

Program(s) of Interest to You

Discovery Courses

7/26 Mommy & Me Baby Class7/25-29 Summer Course Discovery Switch8/1-5 Summer Course Inventor Adventure8/15-19 Summer Course Mad Science8/22-26 Summer Course Art AttackPreschoolGrads (Elementary School Students)Teens (Junior High School Students)Other

Parent/Guardian Information

*Name

*Relation to Child

*Email Address

*Confirm Email Address

*Telephone Number

Home Address

*Postal Code

*Prefecture
HokkaidoAomoriIwateMiyazakiAkitaYamagataFukushimaIbarakiTochigiGunmaSaitamaChibaTokyoKanagawaNiigataToyamaIshikawaFukuiYamanashiNaganoGifuShizuokaAichiMieShigaKyotoOsakaHyogoNaraWakayamaTottoriShimaneOkayamaHiroshimaYamaguchiTokushimaKagawaAisaiKochiFukuokaSagaNagasakiKumamotoOitaMiyazakiKagoshimaOkinawaOutside Japan

*City

*Address Line 1

Address Line 2

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