222 ACademy
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Parent/Guardian Full Name *

First Name

Last Name

Parent/Guardian Phone *

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Student Full Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

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Program Selection *

Select ALL That Apply

Winter Basketball (October - February) - price varies per division

Spring Basketball (March - July) - price varies per division

Cheerleading (Oct - February) - price varies per division

Experience Series (2x per month) - $50/month

Take Flyght After School Program (3 days per week) - with transportation - $130/month

Take Flyght After School Program (3 days per week) - without transportation - $100/month

Mental Health Services (1-on-1, small group) - Billed by insurance. Information provided at consultation.

Academy Kid - Full Immersion (All 4 pillars, 9-month program, 1 flat fee) - $250/month *save up to $900 per year

Does your child currently receive academic or counseling support at school? *

Yes

No

Preferred Method of Contact *

Phone

Email

Text

Parent Agreement *

I confirm the information provided is accurate and I consent to my child’s participation in the selected 222 Academy program(s).

Liability Waiver *

I understand that participation in athletic and enrichment programs involves some risk of injury. By enrolling my child, I agree to release and hold harmless 222 Academy, its staff, coaches, volunteers, and partners from any liability, claims, or expenses arising from participation.

Media Release *

I grant permission for photos, videos, and other media of my child taken during programs, events, and activities to be used by 222 Academy for promotional, educational, and marketing purposes. I understand that no compensation will be provided for such use.