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Price:

*Attendee's First Name:

*Attendee's Last Name:

*Attendee's Email Address:

*Attendee's Phone Number:

Country:

Address Line 1:

Address Line 2:

City, State Zip:

Please make sure the information below is for your 4th/5th Grader or Dream Team Member.

One Registration per person.

Address fields are optional!

*Please select one:

4th/5th GraderDream Team - Yes, I am can serve during Verge Night

*Date of Birth:

*Parent/Guardian's First & Last Name:

*Primary Email :

*Primary Phone:

Emergency Contact Name and phone number:

Registration Total: