Flourish Enrich Registration Form
Parent:
*
First Name
Last Name
Preferred Contact Email:
*
example@example.com
Parent Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Name:
*
First Name
Last Name
Student Birth Date:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student Age:
*
Student Grade:
*
Grade level for 2022-2023 school year
Student Class Selections (listed by hour):
Early Elementary (age 5-7)
Elementary (age 8-11)
Middle (age 12-14)
Day 1: Paid Math Tutoring ($10/1hr small group session)
Day 2: Paid Reading Tutoring ($10/1hr small group session)
Allergies
List the allergy/condition and any special needs or instructions the co-op director and teachers need to be aware of.
Medical Conditions:
List the allergy/condition and any special needs or instructions the co-op director and teachers need to be aware of.
Please verify that you are human
*
Submit
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