BowMed Learning Lab Registration
Email address
*
example@example.com
Student Information First Name: Last Name: Date of Birth: Gender: Address: Phone Number Email Address
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Parent Information: First Name: Last Name: Date of Birth: Gender: Address: Phone Number Email Address
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Parent Information: First Name: Last Name: Date of Birth: Gender: Address: Phone Number Email Address
*
Emergency Contact 1: Name: Phone Number: Relationship to Student:
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Emergency Contact 2: Name: Phone Number: Relationship to Student:
*
Medical Information Any known allergies or medical conditions: Primary Care Physician's Name: Phone Number:
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Consent and Agreements:
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I give permission for my child to participate in tutoring, assessments, and educational services.
I consent to communication regarding my child’s progress.
I understand BowMed Learning Lab is not liable for academic outcomes and as a parent I am responsible for attending parent meetings.
I consent to my child's participation in school activities and events with guest speakers/ fieldtrips
I understand and agree to the school's behavior guidelines.
I consent to my child's medical treatment in an emergency.
I understand that I am responsible for my child's tuition in full each month.
I give permission for photos/videos to be used for educational or promotional purposes (Yes/No)
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What are your child's favorite subjects and activities?
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Reading
Math
Social Studies
Science
Sports
Gaming
Arts (Acting, writing, dancing, singing)
What are your child's strengths, weaknesses and interests?
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How does your child prefer to learn?
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What is your gross income range?
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0-$25,000
$26,000-$50,000
$50,000-$75,000
$76,000-$100,000
$100,000-$500,000
I understand that I am fully responsible for the registration fee of $100 plus any additional tuition cost that may not be covered by grants, scholarships, or any other forms of payment?
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Yes
No
Signature
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