Please print this form and submit by phone, fax or mail to:
3D Learner Inc, 7100 W Camino Real, Suite 215,
Boca Raton, Fl 33433
Reading, Writing, Listening, Processing Skills
Reading is Fun
Intensive One Week Writing Camp
Reading Camp for High School Students
Parent Last Name: Father Mother
Address
City State Zip
Daytime Phone Home Phone
Mother’s Cell Phone Father’s Cell Phone
Email Address
Child’s Name Date of Birth Grade for 2010-2011
How did you learn about our Summer Camp?
Price $ 480 $350 $ $750 Other __________
A deposit of $100 is required for each applicant for each session
10% Discount for early enrollment and full payment by March 31st
Method of Payment: _____Credit Card _____ Check # Authorized Amount $______________
Credit Card Information: _____ Visa _____ Mastercard _____Discover Credit Card # _________________________ Exp. Date:____/____ CVC Code (3 last digits on back of CC) ______ Name on Card _________________________________________________________________________________
Address (if different from above) ___________________________________________________________________
I authorize 3D Learner Inc to charge my credit card for the authorized amount detailed above. __________________________________ Date: _____/_____/_____ Signature