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2023 REGISTRATION FORM

Student
Name:________________________________________DOB____________
M__ F __
Parent/Guardian:
Name:_________________________________________________________
School: _______________________________________release time_______
Grade: ________
My student’s main language is: _____________________
Mailing Address:
___________________________________________________
Parent phone number and email address:
_____________________________________________________________
Student phone number and email address:
______________________________________________________________

The best way to contact me is: __ by phone or __ by email.

Emergency Contact Information (other than parent/legal guardian)

Name____________________________________
Phone____________
Name____________________________________
Phone________________
Focused Subject
____________________
____________________
____________________
____________________

________________________________________________________________
I understand that I will be part of the goal setting process for my student, and I
agree to release the student’s relevant educational information to the
appropriate parties for educational research. Including the student’s report card. I
have read and understand the Company Code of Conduct and will guided by its
parameters.

I have read and understand the Fee Structure, and the need for timely payments.

Parent/ Guardian Signature: _________________________________

Date:_____________________

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