Middle School Package Registration
We're excited to see you're ready to work with us! A $200 deposit (credited to your total package balance) is required in order to begin services, and will be charged when you complete this form.
Name
*
First Name
Last Name
Parent E-mail
*
Parent Phone Number
*
Student's Name
*
First Name
Last Name
Student Phone Number (optional)
Student E-mail (optional)
example@example.com
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Which package are you interested in?:
*
50 Hour Package ($45/hr)
75 Hour Package ($40/hr)
125 Hour Package ($35/hr)
Build Your Own Package (for fewer than 50 hours) ($50/hr)
Please type/input the number of hours you'd like to purchase:
What grade will the student be in for the 2018-2019 school year?
6th grade
7th grade
8th grade
Where does your child attend middle school?
*
Please Select your Preferred Office Location
Gaithersburg Office (18235A Flower Hill Way, Gaithersburg MD 20879)
Potomac Office (1201 Seven Locks Road, Potomac MD 20854)
RIO Satellite Office (9841 Washingtonian Blvd #200, Gaithersburg MD 20878)
Tell us about your student! (hobbies, activities, clubs, sports, games, etc).
How do you intend to pay for sessions? (Only registration fee is due today).
*
In Full - total due within 10 days of first session
Weekly - Payments will be charged weekly at 5:00 pm on Fridays
Monthly - monthly charges made within 30 days of registration
Check/Cash immediately after session is over
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Registration Fee
*
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( X )
Registration Fee
$
200.00
Total
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
By filling out this form, I am agreeing to let Modern Muse Education contact me using the e-mail address and/or phone number listed above within 24 hours of the form submission to begin tutoring:
*
I agree
By filling out this form, I understand: that the registration fee charged today is credited to the course total, that I am welcome to pay the balance in full OR I will be billed for the remaining balance once schedules have been confirmed, that remaining balance will be charged to my account, and that failure to make payments may result in my package being cancelled.
*
I agree
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