The Scribble Room Registration Form
Summer Bootcamp Sessions for Summer 2025
Parent Name
*
First Name
Last Name
Parent Name
First Name
Last Name
Parent E-mail
*
example@example.com
Mobile Number
*
Best contact number.
Child's Name
*
First Name
Last Name
Birth Date
Please select a month
January
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Month
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Day
Please select a year
2024
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Year
Gender
*
Please Select
Male
Female
N/A
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Name of Current School
*
Grade Entering for 2025-2026 School Year
*
Please Select
KG
1st
2nd
3rd
4th
5th
6th
Sessions Per Week
*
Please Select
1
2
Summer Bootcamp Sessions Availability
*
Monday (Winter Haven - AM or Bartow - PM)
Tuesday (Lakeland - AM)
Wednesday (Winter Haven - AM or Bartow - PM)
Thursday (Lakeland - AM)
Friday
Desired areas of focus. Ex: Phonics, Fluency, Writing, Reading Fluency, Reading Comprehension Strategies, Math, etc.
*
Please list any allergies you child may have.
*
Please tell me your about your child's favorite color, animal, hobbies, places to go/visit for fun.
*
Additional Comments or Questions:
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Tutoring Session Requested:
*
Summer Bootcamp Session/Individual ($35.00/Hourly)
Summer Bootcamp Sesson/Small Group of 2-3 Students ($30.00/Hourly)
Preferred Payment Cycle:
*
Please Select
Weekly
Bi-weekly
After registration is complete, there are additional documents that must be reviewed and signed in person.
*
Please Select
Yes
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My Products
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Pencils Crayons and Markers LLC
This fee is comprised of the registration fee, deposit and supplies/materials fee. Please note that this fee must be paid prior to tutoring services starting. Parents determine the start date.
$
25.00
Quantity
1
2
3
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Item subtotal:
$
0.00
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