New Year, New Skills Winter Program

New Year, New Skills Winter Program

Starting January 8th
Application and Registration Form

Small Group classes meet twice per week -totaling 2 hours per week
Date

MonthDayYear
Date
Student's Name

First NameLast Name
Student's Date of Birth

MonthDayYear
DOB
Student's Age
Grade
Gender
Primary Language Spoken at Home
Is the student Right or Left Handed?
Is your child a current or former SCA student?
Were you referred to us by your child's school?
Was your child retained last school year?
Has your child been enrolled in a speech/language therapy program?
Does the student have an IEP ?
Any diagnosis that affects your child’s learning? If so, please explain. If no, please type N/A
What is your expectation of the New Year, New Skills Program?
How did you hear about us?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Does your child require a verification letter of completion of our program?
Choose the desired class below.
Please select the program of interest:

Small Group Reading Only Program 6 weeksSmall Group Math OnlyProgram 6 weeksSmall Group Reading & Math Program 6 weeksSmall Group Reading Only Program 8 weeksSmall Group Math OnlyProgram 8 weeksSmall Group Reading & Math Program 8 weeks
Please list preferred days and times. Please be as flexible as possible. The SCA will match your child with best available class according to your available days and times. Please also list days that your child is unavailable.
My Products
prevnext( X )
Small Group Class 6 Weeks
2 x per week + $25 registration - this includes reading, math, kindergarten preparation programs.

$445.00 Quantity

Small Group Class 8 Weeks
2 x per week + $25 registration - this includes reading, math, kindergarten preparation prorams.

$585.00 Quantity

Total

$0.00

Name of Person Completing the Form

First NameLast Name
Relationship to Child
Please provide the name of the person responsible for registering the student into the winter program. This person will be our primary contact person as well as the person responsible for the financial responsibility associated with registration. .
Relationship to Child
Mother's Name

Mother's First NameMother's Last Name
Mother's Date of Birth

MonthDayYear
Date
Mother's Phone Number
Please provide the primary contact number
Mother's Email Address
Father's Name

Father's First NameFather's Last Name
Father's Date of Birth

MonthDayYear
Date
Father's Phone number
Please provide the primary contact number
Father's email address
Does the student have siblings? If yes, please list below. If no, please type N/A.

Registration is not complete until payment is received. All fees, deposits or payments received are non-refundable. A minimum of 24 hours notice is required to reschedule a group tutoring session.
Which week will your child begin the tutoring program?
I understand and agree with all terms listed above and affirm that all provided information is accurate.
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

Payment Info
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New Year, New Skills Winter Program

Application and Registration Form

Choose the desired class below.

Registration is not complete until payment is received. All fees, deposits or payments received are non-refundable. A minimum of 24 hours notice is required to reschedule a group tutoring session.