EmailMe Form - Simeon Computer Education Institute

Name *
First Middle Last
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Phone *
### - ### - ####
Date of Birth
MM / DD / YYYY
Age *
If you are not eighteen please allow your parents to sign on your behalf.
Skype Name
Parent's Name
Parent(s) Consent
If your child is a minor please select yes indicating you have agreed to pay on their behalf, from the drop down box.
Parent's Phone
### - ### - ####
Email
Kindly ensure your email address is entered correctly
Registration Date *
MM / DD / YYYY
Courses *
All required fields must be completed. Please note that half the course fees must be paid in advance.