Cogito Debate Online Registration

Registration

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Welcome to Cogito Debate! Please complete the following registration form. If you are affiliated with a charter school please fill out registration form only. Credit Card information is not required. Please call for special tuition fee's.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Home or Primary Phone*

Additional Info

Emergency Contact Info
(Not Contact #1 or #2)*

Contact #1

Contact #1 First Name*

Last Name *

How Can We Contact You?

Home Phone

Work #

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilites*

Special Needs*

Allergies*

Medications*

Primary Doctor

Ethnicity

ESL

Please click on the Search button below, then choose the class. PLEASE SELECT THE CLASS LOCATION YOU WILL BE ATTENDING.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilites*

Special Needs*

Allergies*

Medications*

Primary Doctor

Ethnicity

ESL

Please click on the Search button below, then choose the class. PLEASE SELECT THE CLASS LOCATION YOU WILL BE ATTENDING.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilites*

Special Needs*

Allergies*

Medications*

Primary Doctor

Ethnicity

ESL

Please click on the Search button below, then choose the class. PLEASE SELECT THE CLASS LOCATION YOU WILL BE ATTENDING.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilites*

Special Needs*

Allergies*

Medications*

Primary Doctor

Ethnicity

ESL

Please click on the Search button below, then choose the class. PLEASE SELECT THE CLASS LOCATION YOU WILL BE ATTENDING.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date* (format=mm/dd/yyyy)

Cell #

Additional Info

Student Email

School*

Grade Level*

Disabilites*

Special Needs*

Allergies*

Medications*

Primary Doctor

Ethnicity

ESL

Please click on the Search button below, then choose the class. PLEASE SELECT THE CLASS LOCATION YOU WILL BE ATTENDING.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

Photo Release

The Cogito Debate has my permission to use my photograph publicly to promote Cogito Debate. I understand that the images may be used in print publications, videos, online publications, presentations, websites and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

I've read the above and agree.

Class Changes and Refund Policy

Withdrawal requests must be made by submitting a written request 7 days before the first day of class to receive a refund less student registration fee of $50.00. Otherwise, no refund nor credit will be given. No pro-rated tuition or credit will be given for missed classes (NO MAKE UP CLASSES). Classes are subject to change or cancel.

I've read the above and agree.

Attendance Policy

We request that all students attend every class, as new information is introduced each class session. In the event that a student is unable to attend, we request that the student and/or parent coordinate with the coach to get the appropriate materials.
Tardiness: The teacher is available and in the classroom starting 15 minutes prior to class. Students are encouraged to arrive up to 15 minutes early so as to avoid tardiness. If a student is tardy more than two (2) times, a notification will be sent to the parent, along with a request to remedy the situation

I've read the above and agree.

I Agree to All of the Above

Enter your Full Name*

Questions or Concerns

Comments

Payment Information

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

City

State

Zip

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number