Registration Spring 2024
Santa Cruz Learning Center
Participant Name (Student):
First Name
Last Name
DOB of Student:
-
Month
-
Day
Year
Date
Age of Student as of January 2023
5
6
7
8
9
10
11
12
13
14
15
Grade level Spring 2023
TK
K
1
2
3
4
5
6
7
8
9
10
11
12
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 Code
Phone Number
Information for Parent or Guardian 1
Parent or Guardian 1 Full Name:
First Name
Last 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
City
State / 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 Code
Phone Number
Work phone of parent/guardian 1
-
Area Code
Phone 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 Name
Last 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
City
State / Province
Postal / Zip Code
Relationship(s) of parent or guardian 2 to the student (mother, father, etc.)
Cell phone of parent/guardian 2
-
Area Code
Phone Number
Work phone of parent/guardian 2
-
Area Code
Phone Number
Email for parent/guardian 2
example@example.com
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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
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Emergency Contact Information
Please let us know who to contact in the event of an emergency if we are unable to reach Parent or Guardian 1 or 2.
Emergency Contact 1:
First Name
Last Name
Phone Number:
-
Area Code
Phone Number
Relationship to Student:
Emergency Contact 2:
First Name
Last Name
Phone Number:
-
Area Code
Phone Number
Relationship to Student:
Emergency Contact 3:
First Name
Last Name
Phone Number:
-
Area Code
Phone Number
Relationship to Student:
How do you plan to pay for course fees from Santa Cruz Learning Center?
Pay monthly with Ocean Grove PO (Please notify your ES to prepare a purchase order. If you select this option, we must receive a PO from OG before you start classes.
Pay monthly - This will require that you complete a payment agreement form and funds will be automatically withdrawn on the first of each month.
Pay in full at the beginning of the semester. If you choose this option, you will receive a discount of $20 per class. Note that those paying by PO can't choose this option since we can only bill POs once a month.
Some combination of purchase order and self pay.
Other
If paying by self-pay (not by purchase order), who is the person responsible for payment of course fees at Santa Cruz Learning Center?
First Name
Last Name
What is the email of the person financially responsible for course fees?
example@example.com
Phone number of financially responsible person
-
Area Code
Phone Number
Medical Insurance Information
Medical Insurance Carrier
Name of Insured
Policy Number
Group Number
Name of Primary Care Physician:
Phone number of Primary Care Physician
-
Area Code
Phone Number
Name of Dentist:
Phone Number of Dentist:
-
Area Code
Phone Number
Health Information
Does your child take medication?
yes
no
If your child takes medication, please specify with details.
Does your child have asthma?
Yes
No
Does your child carry an inhaler for their asthma?
Yes
No
Has your child been diagnosed with ADD or ADHD?
Yes
No
Is your child allergic to any of the following? Please select all that apply
Bee Stings
Animals
Trees, grasses, pollen
Foods
My child does not have allergies to bees, animals, trees, grasses, pollen or foods.
If you answered yes to any allergies, please describe the reaction and the severity of the allergies that you indicated.
Does your child carry an epipen?
Yes
No
Are there any other health or behavioral conditions or information that you would like to share with us? If so, please describe below.
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COURSE ENROLLMENT SECTION
FOR THOSE OF YOU REGISTERING MORE THAN ONE STUDENT, PLEASE COMPLETE A SEPARATE FORM FOR EACH STUDENT
This section is to enroll in a course for spring semester 2024.
Students who are continuing courses from the fall DO NOT NEED TO REGISTER AGAIN FOR SPRING unless they are adding a course.
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ELEMENTARY COURSES
SKIP THIS SECTION IF NOT ENROLLING FOR ELEMENTARY COURSES
Adventures in Science $625 per semester (In-Person Only)
Tuesdays 12pm-2pm for K-3rd Graders with Liz
Thursdays 11:30am-1:30pm for 4th-6th graders with Jenn
Book Club and Writers Workshop for K-3rd Graders with Jenn $550 per semester (In-Person Only)
Weds 10-11:30 NOTE THE TIME CHANGE FOR SPRING SEMESTER
Elementary Combo Project Class for K-3rd Graders (In-Person Only) with Liz
Tuesdays 9am-12pm for K-3rd graders $900 per semester
Thursdays 10am-1pm for K-3rd graders $900 per semester
Both Tuesday and Thursday $1700 per semester ($100 savings)
Paleontology: 4th-6th graders Tuesdays 1:15-2:15 IN PERSON ONLY with Jenn $450 per semester
Register for Paleontology in person
Writers Workshop for 4th-6th graders with Jenn $450
Thursdays 10:30am-11:30am for 4th-6th Graders
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MIDDLE SCHOOL COURSES
All middle school courses are for 6th-8th graders unless otherwise specified. SKIP THIS SECTION IF NOT ENROLLING FOR MIDDLE SCHOOL COURSES
Adventures in Science: 4th-6th graders. Thursdays 11:30am-1:30pm $625 per semester with Jenn IN-PERSON ONLY
Register for Adventures in Science for 4th-6th graders
American Sign Language 1: 6th-12th grade $600 per semester 10am-11am Tuesdays and Thursdays with Mel
I plan to attend class in-person
I plan to attend class live via Zoom
I plan to sometimes attend class in-person and sometimes via Zoom
Earth Science $600 per semester Mondays 11:30am-1:30pm with Jenn
I plan to attend class in-person
I plan to attend class live via Zoom
I plan to sometimes attend class in-person and sometimes via Zoom
Middle School Life Science $600 per semester Tuesdays 11:15am-1:15pm with Malika
I plan to attend class in-person
I plan to attend class live via Zoom
I plan to sometimes attend class in-person and sometimes via Zoom
Language Arts for 6th-7th Grade $600 per semester Wednesdays 11:30am-1:30pm with Jenn
I plan to attend class in-person
I plan to attend class live via Zoom
I plan to sometimes attend class in-person and sometimes via Zoom
Language Arts for 7th-8th Grade $600 per semester Wednesdays 11:30am-1:30pm with Jay
I plan to attend class in-person
I plan to attend class live via Zoom
I plan to sometimes attend class in-person and sometimes via Zoom
Math Course 1 (6th Grade Math) Mondays & Wednesdays 9am-10am with Mel $600 per semester
I plan to attend class in-person
I plan to attend class live via Zoom
I plan to sometimes attend class in-person and sometimes via Zoom
Math Course 2 (7th Grade Math): Mondays & Wednesdays 1:45pm-2:45pm with Malika $600 per semester
I plan to attend class in-person
I plan to attend class live via Zoom
I plan to sometimes attend class in-person and sometimes via Zoom
Math Course 3/Prealgebra (8th Grade Math) with Malika Mondays & Wednesdays 10:15-11:15am $600 per semester
I plan to attend class in-person
I plan to attend class live via Zoom
I plan to sometimes attend class in-person and sometimes via Zoom
Spanish 1: 6th-12th grade Fridays 10am-12pm with Tim $600 per semester
I plan to attend class in-person
I plan to attend class live via Zoom
I plan to sometimes attend class in-person and sometimes via Zoom
US History and Geography Thursdays 1:30pm-3:30pm with Jenn $600 per semester
I plan to attend class in-person
I plan to attend class live via Zoom
I plan to sometimes attend class in-person and sometimes via Zoom
World History and Geography Mondays 1:30pm-3:30pm with Mel $600 per semester
I plan to attend class in-person
I plan to attend class live via Zoom
I plan to sometimes attend class in-person and sometimes via Zoom
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HIGH SCHOOL COURSES
SKIP THIS SECTION IF NOT ENROLLING FOR HIGH SCHOOL COURSES. Please indicate if you would like to take the course with the a-g option and how you plan to attend.
Algebra 1: For 6th-12th grade Tuesdays & Thursdays 10am-11am with Malika $600 per semester
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
Algebra 2: Mondays & Wednesdays 11:20am-12:20pm with Malika $600 per semester
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
American Sign Language 1: Tuesdays & Thursdays 10-11am with Mel $600 per semester
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
American Sign Language 2: Mondays & Wednesdays 10-11am with Mel $600 per semester
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
Astronomy: Wednesdays 1:45-3:45pm with Jay $600 per semester
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes.
Biology: Fridays 9:45am-12pm with Malika $650 per semester including all materials.
This class is full. Select this option if you want to join the waiting list.
BYO Study Skills with Malika Fridays 12:30-2:30pm $500 per semester
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course both in-person and live via Zoom
Chemistry: Thursdays 11:15am-1:30pm with Malika $650 per semester including all materials.
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
Criminology and Practical Law: Thursdays 1:45pm-3:45pm with Malika $600 per semester
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
Project Based English 10: Tuesdays 1:30pm-3:30pm with Malika $600 per semester
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
Functional English Tuesdays: 1:30pm-3:30pm with Jay $600 per semester
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
Environmental Science: Tuesdays 11am-1pm with Jenn $650 per semester including all materials.
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
Geometry: Mondays and Wednesdays 12:30pm-1:30pm with Malika $600 per semester
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
Economics: Wednesdays 4pm-6pm with Jay $600/semester
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
Project Based History - United States: Mondays 11:10am-1:10pm with Jay $600 per semester
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
Project-Based History - World: Mondays 1:30pm-3:30pm with Jay $600 per semester
This class is full. Select this option if you want to join the waiting list.
Positive Psychology: Fridays 10am-12pm with Melanie $600 per semester
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
Pre Algebra: Mondays and Wednesdays 10:15am-11:15am (a-g option not available) with Malika $600 per semester
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
PreCalculus (Day and time TBD depending on who signs up) with Malika $600/semester
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes.
Enroll in a-g option
Enroll in non a-g option
Spanish 1: Fridays 10am-12pm with Tim $600 per semester
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
Spanish 2: Fridays 12:15-2:15pm with Tim $600/semester
Enroll in A-G option
Enroll in non A-G option
I plan to take this course live via Zoom
I plan to take this course in-person at the learning center
I plan to take this course in-person sometimes and live via Zoom sometimes
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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?
Yes
No
Other
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.
*
In case of illness or accident, Santa Cruz Learning Center, Inc, is authorized to secure emergency medical treatment at my expense.
*
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.
*
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.
Name of person signing this registration form
First Name
Last Name
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