Summer Student Registration Form

Student Registration Form
Student Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Currently Attending (If applicable)
You must enter full name of the school
Current Grade Level
Date of Birth

MonthDayYear
Parent Information

(If applicable)
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Educational Background

Please complete the following questionnaire to help me gain a comprehensive understanding of the student's needs.
Does the student have any special needs or require any accommodations (e.g., IEP, 504 Plan)?
Has the student been diagnosed with any learning disabilities or conditions (e.g., ADHD, autism, dyslexia)?
What are the student strengths?
Are there any specific concerns or challenges your child has faced in previous school years?
What are your educational goals for the student this year?
Availability

Please select ALL the times and days that the student will be available for class.
Classes are available beginning June 8, 2026 — rolling enrollment all summer. Let us know your preferred start date when you reach out!

MonthDayYear
Date
Monday

8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm
Tuesday

8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm
Wednesday

8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm
Thursday

8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm
Friday

8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm
Class List
Available enrollment options include:

HydroponicsKitchen ChemistryDigital MediaEntrepreneurshipCoding & Game DesignCreative WritingAI for KidsFull Year CurriculumGet AheadOther
Enrollment CommitmentTo ensure consistency and effective planning for both students and staff, parents are asked to indicate the duration of their child’s enrollment upon registration. Available enrollment options include:

Summer ProgramFall 2025 Tutoring Semester (August–December 2025)Full Tutoring Year (August 2025–May 2026)Full Homeschool Year (August 2025–May 2026)
Should be Empty:

Student Registration Form

Student Information

Parent Information

Educational Background

Availability

Class List