Glowing Minds New Registration Form

Student Registration Form

Fill out the form carefully for registration
1. Parent's/Guardian's Name

Mr/Mrs/Ms/DrFirst NameLast Name
2. Email
example@example.com
3. Phone Number
Please enter a valid phone number.Format: (868) 000-0000.
4. Area From:

e.g. San Fernando, Couva, Arima, POS, Sangre Grande

Street Address Line 2

City

Postal / Zip Code
5. Student's Name

First NameLast Name
6. Birth Date

MonthDayYear
7. Gender
7. School attending
e.g. Primary School or Homeschool
8. Standard (Currently)
e.g. Standard 4
9. Does your child have any learning needs, diagnoses, or accommodations I should know about?
e.g. Dyslexia, ADHD, Autism
10. Which support option are you interested in?
11. Which subject or area does your child need help with?
12. When do you wish to start?:
13. What has worked well for your child in the past?:

Other
14. What is your biggest concern about your child’s learning right now?
e.g. Dyslexia, ADHD, Autism
15. What would you like your child to improve most?

Other
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Student Registration Form