365 N New Hope Rd, Suite 6
Gastonia, Gaston County 28054 USA

(980) 745-8001

©2019 by eSTEAM Club. 

Registration 

Please complete the form to register your child for eSTEAM Club

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Parent/ Guardian Information

Parent/Guardian Name

Contact

Address

Child 1 Information

Child Name *

Date of Birth

School Information

Teacher's Name

Authorized person to pickup

Additional Information

Please list if your child has any allergies/ medical conditions

Child 2 Information

Child Name *

Date of Birth

School Information

Teacher's Name

Authorized person to pickup

Additional Information

Please list if your child has any allergies 

Child 3 Information

Child Name *

Date of Birth

School Information

Teacher's Name

Authorized person to pickup

Additional Information

Please list if your child has any allergies 

Additional Contact

Contact Name

Relationship

Phone Number