Please Fill Out the Form to Register Your Child

Please enter YOUR information below

First Name *

Last Name *

Cell Phone *

Email *

Address *

City *

State *

Zip code *

2nd Parent Full Name

2nd Parent Cell Phone

Child's Full Name *

Child's Date of Birth *

Child's Gender *

Male

Female

Child's Allergies *

Notes about child *

In addition to those listed above, the following individuals may pickup my child:

Authorized Adult 1 Full Name

Authorized Adult 1 Phone

Authorized Adult 2 Full Name

Authorized Adult 2 Phone

Authorized Adult 3 Full Name

Authorized Adult 3 Phone

What Program are you signing up for? *

Preschool

K-12 Enrichment

Tutoring

Summer Camp

*Please select 1 program. If you need to sign up for multiple programs for your child, we will discuss it at the tour.

What grade does your child need help with?

What subject(s) does your child need help with?

Which Camp Session are you most interested in?

To keep our program running smoothly, please agree to all of these policies:

I agree to pay the monthly tuition by the first class of each month, as well as the non-refundable registration fee to reserve my child’s place and pay for his/her school supplies.

*I agree to pay the tutoring fee before each session to reserve my child's place and pay for his/her tutoring supplies.

*I agree to pay the summer camp fee before the session starts to reserve my child's place and pay for his/her camp supplies.

I give permission for my child’s photograph(s) and/or videotaping(s) to be used for program marketing materials offline and online, newsletters, and art projects.

I agree to abide by the Policies & Procedures Handbook which I will receive.

Parent Agreement *

I agree to all of the policies listed on this form.

Parent Signature

Clear

Date Signed

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