Registration 2023-2024 School Year Santa Cruz Learning Center

Registration 2023-2024 School Year

Santa Cruz Learning Center
Participant Name (Student):

First NameLast Name
DOB of Student:

MonthDayYear
Date
Age of Student as of August 2023
Grade level Fall 2023
School (enter homeschool, if the student is not registered to a school)
Email of Student (if applicable. We ask that middle school and high school students have an email for us to keep track of grades and assignments).
example@example.com
Cell Phone for student, if applicable

Area CodePhone Number
Information for Parent or Guardian 1
Parent or Guardian 1 Full Name:

First NameLast Name
Does the student live full time with parent or guardian 1? If no, please describe when the child stays with parent or guardian 1.
Parent/Guardian 1 Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship(s) of parent or guardian 1 to the student (mother, father, etc.)
Cell phone number of parent/guardian 1

Area CodePhone Number
Work phone of parent/guardian 1

Area CodePhone Number
Email for parent/guardian 1
example@example.com
Information for Parent or Guardian 2

Leave blank if only Parent or Guardian 1 is the only Parent or Guardian
Parent or Guardian 2 Full Name:

First NameLast Name
Does the child live full time with parent or guardian 2? If no, please describe when the child stays with parent or guardian 2.
Parent or Guardian 2 address Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship(s) of parent or guardian 2 to the student (mother, father, etc.)
Cell phone of parent/guardian 2

Area CodePhone Number
Work phone of parent/guardian 2

Area CodePhone Number
Email for parent/guardian 2
example@example.com

Participant Information

Tell us a little about the student
Has your child been diagnosed with any learning exceptionalities and do they have an IEP or a 504 plan?
If you answered yes to the question above, please provide us with more information. If applicable, could you share their IEP or 504 plan report with our education team? Do you have specific tools and/or learning/teaching strategies that have been successful? Are there accommodations that we should be aware of?
What is the name of your ES or Educational Consultant?
Education Specialist/Consultant Email
example@example.com

COURSE ENROLLMENT SECTION

FOR THOSE OF YOU REGISTERING MORE THAN ONE STUDENT, PLEASE COMPLETE A SEPARATE FORM FOR EACH STUDENT

RELEASE SECTION
Photo/video release: Santa Cruz Learning Center may use the above-listed participant's photo for promotional purposes. Does Santa Cruz Learning Center have permission to use photos or videos of your child?

YesNoOther
The parent or guardian signing on behalf of Member shall be responsible for payment of amounts owed to Santa Cruz Learning Center under this Agreement.*

Clear
In case of illness or accident, Santa Cruz Learning Center, Inc, is authorized to secure emergency medical treatment at my expense.*

Clear
The Santa Cruz Learning Center reserves the right to dismiss any participant who does not show respect for the facility, including but not limited to property, equipment, policies, other members, volunteers, and staff. Participants who are dismissed will not be given a refund of fees paid.*

Clear
The Santa Cruz learning center and its employees, contractors and volunteers assume no responsibility for personal property. By signing this enrollment form, I (we) herby waive any and all claims against Santa Cruz Learning Center and its employees, independent contractors and volunteers. I understand and agree that by signing this agreement, I am giving up my (or the minor for whom I sign) right(s) to make any claim against Santa Cruz Learning Center, its agents, employees, volunteers and independent contractors, including the right to sue them, for bodily or personal injury or property damage or any other loss that I might suffer while using Santa Cruz Learning Center services, except as limited by law.

Clear
Name of person signing this registration form

First NameLast Name
Should be Empty:

Registration 2023-2024 School Year

Information for Parent or Guardian 1

Information for Parent or Guardian 2

Participant Information

Emergency Contact Information

Medical Insurance Information

Health Information

COURSE ENROLLMENT SECTION

ELEMENTARY COURSES

MIDDLE SCHOOL COURSES

HIGH SCHOOL COURSES

RELEASE SECTION