Oregon Learning Pod Registration Form

Learning Pod Registration Form

Welcome new Quantum Montessori families! Thank you for choosing Quantum for your child’s educational needs. Please fill out our form for each child you would like to enroll at Quantum. Your deposit is required to hold your child's spot during registration. You will be asked to complete a longer enrollment package if a spot is immediately available in your desired program. In the event that a program is currently full, we will place you on a waiting list and follow up with you as soon as an opening becomes available.
Student Information
First Name*
First Name
Middle Name
Last Name*
Date of Birth*
Last Name
Curent Grade Level*
Does your child have any allergies or medical conditions?*

YesNo
If yes, please specify
Is your child currently taking any medication?*

YesNo
If yes, please specify

Previous Education
Are you transferring from another school? If yes, please fill out the following information.*

YesNo
Reason for leaving other school and choosing a learning pod:*
Previous School 1
School Name
City
State
Dates of Attendance

MM/DD/YYYYMM/DD/YYYY
Previous School 2
School Name
City
State
Dates of Attendance

MM/DD/YYYYMM/DD/YYYY
Previous School 3
School Name
City
State
Dates of Attendance

MM/DD/YYYYMM/DD/YYYY
Would you like to add any additional details?

Referrals

When a student enrolls in one of our programs and uses your referral code, you'll receive a $50 one-time credit. Referrals must commit to our program for the full semester before payout. You can track referrals via your student account.
Your Unique Referral Code
How did you hear about us?*

FacebookInstagramYoutubeReferral (see next question)GoogleOther
Do you have a referral code from a friend or family member? Enter it here so they may receive credit the referral.

Parent/Guardian Information
Full Name*

First NameLast Name
Relationship to Student*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cellphone Number*
Please enter a valid phone number.
Home Phone Number*
Please enter a valid phone number.
Employer
Work Phone Number (Emergency Use)
Please enter a valid phone number.
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Two Emergency Contacts
Name*

First NameLast Name
Relationship To Student*
Phone Number*
Please ensure accuracy
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name*

First NameLast Name
Relationship To Student*
Phone Number*
Please ensure accuracy
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please inform the office of any other vital information you think they may need to know in the event of an emergency.*

Parent Agreement
The registration fee will be processed today, and it is non-refundable. Once your registration documents have been reviewed and the Family and Student Handbook has been signed, you will be able to pay your tuition. This must be done 30 days prior to the start of school.

By signing and submitting the application and payment, you acknowledge that you have read, understood, and agreed to our School's Policies.

e-signature
Today’s Date
Type your full name
Signature

Clear

Registration Fee Payment

If you are using ESA funds, other resources to assist with your family investment, or you would prefer to pay on another date, skip the payment process. We will send you an invoice after receiving your completed form. Your enrollment will not be completed until we receive your family investment

Part Day

TU/TH Part-Day2-days in-person (4-hours)

$599.00

M/W/F Part-Day3-days in-person (4-hours)

$898.00

M - TH Part-Day4-days in-person (4-hours)

$1,198.00

Full Day

TU/TH Full-Day2-days in-person (8.5 hours)

$1,398.00

M/W/F Full-Day3-days in-person (8.5-hours)

$1,796.00

M - TH Full-Day4-days in-person (8-hours)

$2,395.00

Enter coupon

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Learning Pod Registration Form

Student Information

Previous Education

Learning Pod Selections

Referrals

Parent/Guardian Information

Two Emergency Contacts

Parent Agreement

Registration Fee Payment