Student Name:___________________________________________ Grade:___________

School:___________________________________________________________________ 

Parent Name:__________________________________ E-mail:_____________________

Address:__________________________________________________________________ 

Phone:__________________________ Fax:_________________________


Fees:
One time Math Circles materials fee $22.50

Choose the tuition fee payment option:


One cheque
Dated Feb/1
$247.50


Two cheques
Dated Feb/1, Apr/15
$151.50


Five cheques
Dated Feb/1 through to Jun/1
$ 60.60


Make your cheque(s) payable to Math Potentials Training (MPT). 

Mail the registration form and payment to: 

Math Potentials
P.O. BOX 72001 
SASAMAT W 10th Ave 
Vancouver, BC V6R 4P2

Please read the Regulations and sign below.
Parent signature: _______________________________________________________