Please note that parents should fill out separate form per student if siblings are registering for our program. This form is for Fall 2024 courses at Irvine Math Academy.Is your student attending for the first time?* First Time Continuing Returning Referral (If a friend or relative referred you, please specify the name.)* Please let us know how you found us! (friend, advertisement, online etc.)Courses*Please place a check mark next to the course(s) you'd like to register for.Fall 2024 ScheduleMondays (9/9, 9/16, 9/23, 9/30, 10/7, 10/14, 10/21, 10/28, 11/4, 11/11, 11/18, 11/25, 12/2, 12/9, 12/16) AP Calculus BC (7:00 P.M. ~ 9:00 P.M.) Sundays (9/8, 9/15, 9/22, 9/29, 10/6, 10/13, 10/20, 10/27, 11/3, 11/10) Math Olympiads AMC 10 Thursdays (9/5, 9/12, 9/19, 9/26, 10/3, 10/10, 10/17, 10/24, 10/31, 11/7, 11/14, 11/21, 12/5, 12/12, 12/19) AP Pre-Calculus (7:00 P.M. ~ 9:00 P.M.) Registration FormStudent's Legal First Name* Student's Legal Middle Name OptionalStudent's Legal Last Name* Nickname If there is a preferred name you'd like to use, please let us know.Student's Date of Birth* Month Day Year Gender* Male Female Home phone number*Cell numberStreet Address (please no P.O.BOX)* Address Line 2 City* State* Zip Code* Emergency Contact + Relationship* Emergency Contact's number*Current School* Current Math Course at School* Current Grade Level* 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade Student's Email No naver or hanmail please. Please do not use parent's email here in this field. You can either use your child's email address or leave it blank.Parent's Email* Enter Email Confirm Email (No naver or hanmail emails please)Check below for email updatesIrvine Math Academy, LLC Policy and AttendanceChecking below indicates that my child and I agree to the following policy:* All students are supposed to attend all the classes online. Therefore, attendance is the student’s responsibility. Students are expected to login on time and logout on time. There will be no make-up classes for the missed ones. When students sign for the class(es) listed above, the tuition is supposed to be paid in full. There will be NO refund or adjustments in tuition for absences due to illness or schedule conflict or ANY other reason(No carry over for any reason or applying any credit from previous semesters). All tuition are supposed to be paid in advance in order for us to secure a spot for the student. Evaluation of class size and other factors makes your placement in classes not guaranteed. Payment must be received within 7 days of the registration, otherwise the student will be removed from the class list. You acknowledge that Irvine Math Academy, LLC is not a dependent care facility but is a tutoring program. Irvine Math Academy, LLC does not qualify for IRS Publication 530 tax deductions. ConfirmationPayment Method* Credit Card Zelle Total $0.00 Credit Card DiscoverMasterCardVisaSupported Credit Cards: Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name Please note that ONLY U.S. credit cards and debit cards are allowed. Coupon Checks must be payable to: Mohamad Youssef15642 Sand Canyon AveUnit 54064Irvine, CA 92619 Please pay with Zelle using this email address: [email protected] Parent / Guardian's Name* First Last Signature of Parent /Guardian*Signing above indicates that my child and I agree to the all policies listed in this form. I, the Parent/Guardian acknowledge class prices and provided accurate personal information.Date Signed* MM slash DD slash YYYY You have not selected a course. Please return to the top of the form and select at least one course. Otherwise, the registration will be invalid.Please review all the information you entered below and then click next at the bottom of the page!{all_fields} Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code IMPORTANT NOTICE Please press SUBMIT (below) only once. Otherwise, your credit card will be charged twice. Δ