RVA Summer Enrollment Form

Student's Name

Please enroll my child for the following:

Student's Current Age

Parent's Name

Zip Code

Email Address -We respect your privacy and will not share outside of Starz.

Phone

Does your child have a medical condition in which we should be aware of? If Yes, please explain.

Authorized adults able to pick your child up from Starz Class (if not picked up from school teacher or administrator).

Preferred Method of Contact

Additional Notes

Starz Program Policies and Waiver

I agree to the policies and waiver set forth by The Starz Program. Digital signature
Hold your mouse cursor down and drag your finger to form your electronic signature in the box.

Clear

Please note: enrollment is not complete until you verify, pay and click send.

Verification