The Scribble Room Learning Center Registration Form
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
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Day
Please select a year
2026
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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 or Previous School
*
Grade Entering for 2024-2025 School Year
*
Please Select
VPK
KG
Sessions Per Week
*
Please Select
3
4
5
Please list any allergies you child may have.
*
Please list any developmental concerns, delays and/or questions that you 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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Full Day/Half Day Session:
*
Full Day Sessions
Half Day Sessions
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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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.
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
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