Course Registration Form

Student Registration Form

Fill out the form carefully for registration
Student Name

First Name Middle Name Last Name
Birth Date

Month Day Year
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Student E-mail
example@example.com
Mobile Number
Phone Number
Work Number
Company
Courses
Additional Comments
Age
Grade
GPA
Height
Ethnicity
What school do you plan to attend?
Are you a parent?

Yes No
Are you a US citizen?

Yes No
Are you adopted?

Yes No
My Products
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Express Package Gold Gold Package One time Setup fee of $40 $175 Monthly Subscription- Will be paid charged to the card on file at the 1st of each month. FAILURE TO PAY WILL RESULT IN CANCELLATION OF MEMBERSHIP. Can start membership back by notifying The Scholarship Lady via email or text. A fee will not be included. Gold Package Includes: · Unlimited Scholarships (5 @ a time) · Unlimited Essay edits · FASFA Assistance · Monthly 30 minute session with The Scholarship Lady to go over productivity · The Scholarship Lady's Step by Step Tutorial videos · Free Scholarship Lady workbook · Special program assistance in your region · The Scholarship Lady's Newsletter
$ 215.00

Total

$ 0.00
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