Innovative Learning Program Enrollment Form

Student Enrollment Form

Fill out the form carefully for registration
Student Name*

First NameMiddle InitialLast Name
Student Information*

Current GradeCurrent School
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Please list any learning disorders/disabilities. If there are NONE, please type "NONE."*
Internet Access Permission: Please indicate "Yes" or "No" *
Video/Photo Access Permission: Please indicate "Yes" or "No" *
School Testing Data Access Permission: Please indicate "Yes" or "No" *
Mother's Name*

First NameLast Name
Mother's Contact Number*

Area CodePhone Number
Mother's E-mail Address*
Father's Name*

First NameLast Name
Father's Contact Number*

Area CodePhone Number
Father's E-mail Address*
Emergency Contact Name (if parent is not available)*

First NameLast Name
Emergency Contact Relationship to Child*
Emergency Contact Phone Number*

Area CodePhone Number
Service of Interest:*
Please indicate what you are requesting for the "Other" designation:
I would like to request the following "Other" services:
Responsible for Fees (if applicable):*
I have read and agree to the Financial Policies of Innovative Learning, Inc. as referenced at this link (Copy this link into a new tab: https://form.jotform.com/230593790635059 ). Please indicate "Yes" or "No."*
If the Financial Policy link is not operable, please call 704-750-5930 to receive a copy in your email.
Health Care Needs: Please indicate the health conditions we need to be aware of for your child, otherwise please type "Does not apply"*
Doctor's Name
Doctor's Phone Number

Area CodePhone Number
Hospital Preference*

NamePhone
Additional comments: Is there anything else that you want us to know?
Welcome to Innovative Learning, Inc.! A team member will reach out to you to confirm receipt and next steps.
Please sign your Child's Enrollment Form electronically below. Thank you!

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Student Enrollment Form