LEAPSTART 2020-21 SCHOOL YEAR PROGRAM REGISTRATION FORM

2020-21 LEAPSTART SCHOOL YEAR

Learning Pod PROGRAM

ENROLLMENT FORM

Existing Student? *

Existing Student Name *

Child's Information

First Name *

Last Name *

DOB *

Date

Gender *

School Name *

Grade *

Home Street Address *

City *

State *

Zip Code *

Referred By

Parent"s Information

Mother"s Name *

Mom's E-mail *

example@example.com

Mom's Phone *

Father"s Name *

Dad's E-mail *

Dad's Phone *

Dad's Employer *

Mom's Employer *

Emergency Work Phone(s)

For onsite program, Allergies or other medical conditions

2020-21 SCHOOL YEAR

*PLEASE NOTE*

SEATS ARE LIMITED DUE TO SOCIAL DISTANCING MEASURES IN PLACE

*Full Day 8:00AM - 6:00PM SCHOOL SESSION ASSISTANCE & HOMEWORK HELP PROGRAM, LUNCH N SNACKS PROVIDED

*School Time 7:45AM - 2:00PM SCHOOL SESSION ASSISTANCE & HOMEWORK HELP PROGRAM, LUNCH N SNACKS PROVIDED

*After School 2:00PM - 6:00PM AFTER SCHOOL HOMEWORK HELP PROGRAM, SNACKS, FRIDAY FUN ACTIVITIES INCLUDED

*NEW* SATURDAY SOCCER/ HIKING PROGRAM, SNACKS PROVIDED

CHOOSE HOURS

10:00AM - 12:00PM 4:00PM - 6:00PM

*NEW* ONLINE HOMEWORK HELP & GROUP ACTIVITIES PROGRAM, 2 HRS A DAY

CHOOSE HOURS

2:30PM - 4:30PM 3:00PM - 5:00PM

CHOOSE START DATE *

Date

CHOOSE LOCATION *

10650, BUBB RD, CUPERTINO CENTER 10594, S. DE ANZA BLVD, CUPERTINO CENTER DECIDE LATER

CONFIRM PROGRAM *

8:00AM - 6:00PM 8:00AM - 2:00PM 2:00PM - 6:00PM

I understand and agree that a non-refundable registration fee of $75 shall secure a space for my child until the requested start date.

REGISTRATION FEE *

Calculated Total *

REGISTRATION FEE *

USD Leapstart 2020-21 School Year Program Fee

Pay by Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code