The Village Tutorial and Enrichment Program After Care Extended Programming

The Village Tutorial and Enrichment Program Registration Form
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
Expected Start Date

MonthDayYear
Date
Expected Departure Date

MonthDayYear
Date
School Attending blanks .
Grade Attending
Attendance Schedule Choice
Which program are you wanting to register for?*
Student Information
First Name*
Last Name*
Gender*

FemaleMale
Birth Date*

MonthDayYear
Home Phone*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Health Care #*
Doctors Name*

First NameLast Name
Doctors Phone Number*
Parent/Guardian Information 1
Full Name*

First NameLast Name
Home*
Cell
Work
E-mail*
example@example.com
Address - Same As Child*

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Parent/Guardian 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information 2
Full Name

First NameLast Name
Home
Cell
Work
E-mail
example@example.com
Address - Same As Childs

YesNo
If your address is different than the childs please fill out the info below. Otherwise move onto the next section.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Other Infomation
Is your child immunized?*

YesNo
Does your child have any allergies?*

YesNo
If yes please list, including any food or drug allergies.
Does your child have any medical conditions?
Does your child require any medication? If yes, please list these medications.
Do you authorize us to administer the medications listed above?

YesNo
Please list the people authorized to pick up your child. Please be prepared to show proper identification.
Does your child have any siblings?*
If yes, what is their age(s)?
Comments
Emergency Contact - Other than Parent/Guardian
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home*
Cell
Work
All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.
Signature

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The registration fee to participate in our program is $25.00 per child. This fee will be applied to the first program selection weekly fee.

The weekly tuition for The Village Tutorial and Enrichment Program after school service is $100.00 that includes snack, reading or math tutoring and core content enrichment with S.T.E.M. activities. Dinner will be added with family interest.

Specialty camp fees are $125.00 per week. There is a ten percent sibling discount available for families.

We look forward to serving you and creating moments to remember.
Program Services Payment (Please identify program registered.)

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Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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The Village Tutorial and Enrichment Program Registration Form

Student Information

Parent/Guardian Information 1

Parent/Guardian Information 2

Other Infomation

Emergency Contact - Other than Parent/Guardian