Enrollment Form

LanguageBird Enrollment Form

Smart bird! We can't wait to have you learn with us! Please note it may take 5-7 school days to get matched with an instructor.
Student Information
Student Full Name *

First Name Last Name
Home Phone Number *

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
Student Email *

Confirmation Email
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Sex *

Male Female
Date of Birth *

Month Day Year
Date
High School *
Required if student is in High School
High School Graduation Year
Required if student is in High School
Google Hangouts Gmail Address:
Get it for free here: https://hangouts.google.com/
Parent Information

*Required if student is under the age of 18.
Parent Full Name

First Name Last Name
Parent Email
Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Course Information
Language? *
Choose your language option from the dropdown menu.
Course Level? *
Give us your best guess! Course Level (1-6)
Have you taken any courses or have prior experience with the language?
None is needed. We'd just like to know what you've done!
Do you have an IEP, 504 plan or need to request any learning accommodations?
High School Students: If we know, we can determine how we can help.
What is your first choice for day/s of the week and time would you like to take your lessons? *
*This will help us match you with a teacher. Please indicate your time zone and am/pm.
What is a second option for day/s of the week and time would you like to take your lessons? *
*This will help us match you with a teacher. Please indicate your time zone and am/pm.
When would you like to start? *
When would you like to start your lessons? (Note: 5-7 days required from enrollment to start date.) *

Month Day Year
Payment Information

Program Type: *

Full Year Course for Credit - Tuition: $ 2,275.00

Single Semester Course for Credit - Tuition: $ 1,250.00

Semester Options

Tutoring or Test Prep Lessons $ 510.00

Tutoring/Test Prep Lessons

Conversational Lessons $ 445.00

Conversation Lessons

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Confirmation *
Parent Signature *

Required if student is under 18 years of age. Clear
How did you originally hear about LanguageBird? *
Lead Source
Lifecycle Stage
Should be Empty:

LanguageBird Enrollment Form