School Year Registration Form

School Year Registration Form
Please complete and return registration.

Full payment is due upon registration (A $28 supply fee is due with registration.)

Make checks payable to LEARN Strategies.
Date

Month Day Year
Student's Name

First Name Last Name
Date of Birth

Month Day Year
Age
Sex

Male Female
Grade 2014
School
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Child's Name

First Name Last Name
Date of birth

Month Day Year
I/We, as legal guardians(s), do hereby grant LEARN Strategies the right to authorize emergency medical treatment for my child in the event that I or my designated representative cannot be reached. I agree to hold harmless LEARN Strategies and it’s agents from liability arising out of an accident situation. North Carolina Good Samaritan Law will apply.

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Parent/Guardian Signature

Clear
Date

Month Day Year
I/We give permission to LEARN Strategies to use, for publicity and marketing purposes, photographs of statements from, and work produced by my child in the summer Program. (Student’s names are excluded with his/her photo.)

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Parent/Guardian Signature

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Date

Month Day Year

Please indicate tutoring choice for Individual or Small Group Tutoring
Small group minimum of 3 students for $45 rate.

Groups with 2 students are $60 per hour.
Tutoring requested in the following subject area(s)

Reading Comprehension Written Expression Spelling and Reading (Orton-Gillingham) Math Handwriting Other
Other evaluations or information pertinent to the success of your child's learning

Cancellation and Refund

Complete refund of payment minus a $50 processing fee will be given when cancellation of service is 30 days or more prior to the start of classes. No refund of payment with cancellation 30 days or later prior to the start of services.
Payment of Services

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I have mailed a check payable to LEARN Strategies.
Signature

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Date

Month Day Year
Should be Empty: