Converge Hybrid Early Elementary Fall 2024 Class

Class Information

Students ages 4 - 7 may enroll in our Spark! class (early elementary). Our fall semester will run from September 18 - December 11 (no class on November 27). Class is held each Wednesday at Miss Stacie's home tutoring classroom. Once you sign up, you'll receive more location information. Please call or text Stacie at 620-605-2500 if you have questions or would like to see the space before you register.

Pricing

Each semester requires a $25 registration fee. This fee covers your student's curriculum fees and supplies.

Class fees are $150 per semester ($12.50 per class, 12 classes)

Total registration and class fee for the entire 2024 Fall Semester is $175 for full payment or $180 for installment payments (includes $5 installment fee). You may pay in full, two installments, or monthly from September - December.

If your student would like to try out the class before committing for a full semester, you may do one drop-in class for $20. Please fill out all the details on the registration form and choose drop-in.

Class Schedule (Subject to Change, All Times Approximate)

9:00 AM: Morning Basket

9:15 AM: Phonics (or Reading) Around the Campfire - curriculum choice will depend on enrolled students

9:45 AM: Math Games & Review

10:15 AM: Science, Art, Music, and P.E. (Based on Weekly Themes)

11:30 AM: Student Dismissal
Required fields
Page 1 of 6

Parent/Guardian Information
1st Parent/Guardian Name

First NameLast Name
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Parent/Guardian Name

First NameLast Name
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
E-mail
example@example.com
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Student Information
Name of Student

First NameMiddle NameLast Name
Grade in September 2024
Birth Date

MonthDayYear
Gender:
Medical Needs for Child 1
Does your child have any medical/behavioral issues of which we should be aware?
Please explain your child's medical/behavioral needs here
Does your child have any allergies?
Please describe your child's allergies here
Is your child on any regular medication?
Please list your child's regular medications here.
Does your child receive an special services (i.e. IEP, speech therapy, reading tutoring, etc.)?
Please explain the type of help he/her receives here.
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Payment Details
Payment Options
Would you like to pay by check (or cash) or credit card?
Please choose your payment option:
PAYING BY CHECK

Your application will not be final until we receive your first payment.

Make all checks payable to "Converge Space LLC". You may contact me to drop the check by or mail to:

Converge Space LLC
809 Main Street
Winfield, KS 67156

Credit Card Option (If you prefer to pay by credit card, please fill out this section now. If you are paying by cash or check, DO NOT fill out this part. Please note, all credit card charges are secure through Stripe payment processing. I do not have access to your credit card information.)

Full Semester (1 Payment)$175.00

Registration Fee of $25 - Class Fee of $150 ($12.50 per class) - Save $5 by paying in full!

Full Semester (2 Payments)$90.00

2 Payments - one due at registration, the 2nd due by October 1, 2024

Full Semester (4 Monthly Payments)$45.00

4 Payments, Payment 1 at registration, payment 2 by October 1, 2024, payment 3 by November 1, 2024, payment 4 by December 1, 2024.

Drop-In Class$20.00

Give our Spark! program a try. This drop-in option allows your student to attend one trial class. Please leave the date your child will be attending in the comments at the bottom of this section.

Total $0.00

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Drop-In Class
If you signed up for a drop-in class, please put the date your child will be attending in the comments below.
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Class Fees
Once you submit this Converge Spark! Registration Form, you are legally obligated for the semester class amount. If you sign up for a drop-in, you are legally obligated for the $20 class fee.

Semester class fees and registration are non-refundable. Special consideration or credit may be given for hardships. Please contact Stacie if you find yourself in this position.
EMERGENCY & MEDICAL INFORMATION
Medical Authorization: If, in the opinion of a properly licensed and practicing physician, Student needs medical attention which requires Parent's pre-authorization or consent, Parent hereby authorizes, appoints and empowers the Tutorial to act as Parent and furnish such consent on Parent's behalf. Parent confirms that it is Parent's desire that Student be furnished with such medical or surgical services as soon as reasonably possible after the need arises. Parent hereby releases and holds the Tutorial harmless from any liability which might arise from the giving of such consent. Parent agrees to reimburse the Tutorial for any medical expenditures made on Student's behalf.

Consent to On-Site Medical Care: The Parent hereby authorizes the Tutorial to supply medical care as needed for Student (including administration of allergy medications. Epi-Pens, etc. according to the Student's prescription from a licensed practitioner) or other minor medical care as determined to be appropriate by the Tutorial personnel. Parent hereby releases and holds the Tutorial harmless from any liability which might arise from the provision of such medical care.
Emergency Contact (besides parent)
Phone Number of Emergency Contact
Doctor/Medical Group Name
Phone Number of Doctor/Medical Group
Insurance Company Name
Phone Number of Insurance Company
Please check "Yes" to provide your consent.
Liability Waiver
I/we give permission for my child to participate in all class/tutorial sponsored activities and absolve the tutorial from liability to me or my child because of injury to my child at class or during any tutorial activity.

I/we agree to hold harmless Converge Space LLC and its affiliated organizations, employees, agents, and representatives, including volunteer and other drivers, from any and all claims arising from my child’s participation. This release agreement does not apply to claims of intentional (criminal) misconduct or gross negligence by the tutorial, its employees, or volunteers. If such circumstances are proved in a court of law, I/we acknowledge and agree that the school can assume no financial liability beyond its actual liability insurance policy in force.
Required field
MEDIA ACKNOWLEDGMENT
I further grant permission for Converge Space LLC to use my child’s image and voice in printed & electronic materials, with the knowledge that no last names will be used on a public document.

Please check "Yes" or "No" to provide your consent.
Required field
Authorize your consent by typing the name of one parent or guardian here:
Once you push submit, you will receive an email with the registration information you've provided. Please check in spam if you do not see it as it will be from Jotform. After I've reviewed your information, I will reach out to contact you within 48 business hours. If you've chosen to pay via credit card, I will process the payment after your registration review. Charges will be from Converge Space LLC.
Should be Empty:

Class Information

Parent/Guardian Information

Student Information

Medical Needs for Child 1

Payment Details

Payment Options

Credit Card Option (If you prefer to pay by credit card, please fill out this section now. If you are paying by cash or check, DO NOT fill out this part. Please note, all credit card charges are secure through Stripe payment processing. I do not have access to your credit card information.)

Drop-In Class

Class Fees

EMERGENCY & MEDICAL INFORMATION

Liability Waiver

MEDIA ACKNOWLEDGMENT