Learning Lab Application

Learning Lab Application

Thank you for your interest in the PCHC Learning Lab. The Learning Lab is a small, approval-based program intentionally designed to maintain a calm, structured, and respectful learning environment. Enrollment is limited to ensure appropriate group dynamics, clear expectations, and a high-quality experience for all participants. Submission of an application allows us to determine program fit and does not guarantee acceptance.
Primary Contact Information

Please provide your contact information.
Parent/Guardian Full Name*

First NameLast Name
Parent/Guardian Email Address*
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.
Relationship to Student*
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Authorized Persons for Pick Up (other than parent/guardian). List full names & relationship to child(ren).
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship to Student*
Emergency Contact Phone Number*
Please enter a valid phone number.
Student Profile

Please provide details about the student being registered.
How many students would you like to include in this application?*
Student 1: Full Name*

First NameLast Name
Student 1: Date of Birth*

MonthDayYear
Date
Student 1: Grade Level*
Student 1: Does the student have any allergies or medical conditions? If yes, please specify.
Student 2: Full Name*

First NameLast Name
Student 2: Date of Birth*

MonthDayYear
Date
Student 2: Grade Level*
Student 2: Does the student have any allergies or medical conditions? If yes, please specify.
Student 3: Full Name*

First NameLast Name
Student 3: Date of Birth*

MonthDayYear
Date
Student 3: Grade Level*
Student 3: Does the student have any allergies or medical conditions? If yes, please specify.
Student 4: Full Name*

First NameLast Name
Student 4: Date of Birth*

MonthDayYear
Date
Student 4: Grade Level*
Student 4: Does the student have any allergies or medical conditions? If yes, please specify.
Student 5: Full Name*

First NameLast Name
Student 5: Date of Birth*

MonthDayYear
Date
Student 5: Grade Level*
Student 5: Does the student have any allergies or medical conditions? If yes, please specify.
Program Fit & Readiness

The Student Drop Off Pilot is designed for students who can participate independently within a small, supervised group. The questions below help us determine whether this environment is a good fit.
In a few sentences, describe your child(ren)’s ability to work independently in a group setting.*
Is there anything else you’d like us to know as we consider your application?
Acknowledgements
Please review and acknowledge the following before submitting your application:
- This program operates as structured homeschool workshops (not childcare). Parents retain full educational responsibility per FL Statute 1002.41. No general supervision beyond scheduled activities.
- My child is expected to participate independently in a supervised group setting.
- This is a fixed, 8-week pilot, and missed days do not qualify for makeups or refunds.
- Participation is by approval only, and submitting this application does not guarantee acceptance.
- The program is not equipped to provide one-on-one support or specialized services.
- My child must arrive healthy and able to participate safely in group activities.
- Late pickup may result in a fee and may affect continued participation.
- I understand that full program details, expectations, and policies are available at www.PlantCityHomeschool.org
Signature*

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Signer's Name

First NameLast Name
Date

MonthDayYear
Date
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Learning Lab Application

Primary Contact Information

Emergency Contact Information

Student Profile

Program Fit & Readiness

Acknowledgements