Registration Form

Registration Form

Thank you for your interest in our programs. To ensure we have the most accurate information to support your student’s needs, we kindly ask that you complete this registration form carefully and thoroughly. We work hard to make sure our programs are the right fit for every student. This registration helps us start that process. Enrollment is based on our current availability. We truly appreciate your interest in joining our community and will be sure to keep you updated every step of the way!
Student Name

First NameLast NamePreferred Name
Birth Date

MonthDayYear
Gender
Grade Level
For 2026-2027 school year
School name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Name

First NameLast Name
Parent Email
example@example.com
Mobile Number
Format: (000) 000-0000.
Based on recent assessment scores, classroom observations, and your own insights at home, how would you describe your child’s current level of reading proficiency?
Based on recent assessment scores, classroom observations, and your own insights at home, how would you describe your child’s current level of math proficiency?
I would like the student to participate in the following (Select all that apply):
Please provide all student availability (Ex: Monday/Morning or Tuesday/After 6p)
Additional Comments
Should be Empty: