* Required

Student First Namerequired

Student Last Namerequired

School Namerequired

E-mailrequired

Phonerequired

Typerequired

Address Line 1required

Address Line 2

Cityrequired

U.S. State

Or Province/Region (outside U.S.)

ZIP or Postal Coderequired

Country (outside U.S.)

Name to appear on Zoom accountrequired

This name will be used to verify your participation in the Zoom waiting room.

Registration Fee

Interested in registering more than one person? Contact tsmith@perkiomen.org for group registration.

Please send a confirmation email to the address below*: