In Person Learning Pod Registration Form

Learning Pod Registration Form

Welcome to Quantum Montessori a Heart Centered Brand! 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
This is your student identification number. Please keep it safe, as it will stay with your child for the entire duration of their enrollment and beyond.
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.Format: (000) 000-0000.
Home Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Employer
Work Phone Number (Emergency Use)
Please enter a valid phone number.Format: (000) 000-0000.
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 accuracyFormat: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name*

First NameLast Name
Relationship To Student*
Phone Number*
Please ensure accuracyFormat: (000) 000-0000.
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
Please read, review, acknowledge, and sign this Enrollment Agreement. All terms and conditions are binding. You will receive a copy via email after signature.
Today’s Date
Type your full legal name*
Signature*
Students Name*

First NameLast Name
Should be Empty:

Learning Pod Registration Form