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
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Please Select
Male
Female
N/A
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
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:
Back
Next
Tutoring Session Requested:
*
Summer Bootcamp Session/Individual ($40.00/Hourly/Self-Pay)
Summer Bootcamp Session/Individual ($45.00/Hourly/Step-Up for Students Scholarship)
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
Clear Fields
My Products
prev
next
( X )
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
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Submit Application
Should be Empty: