MommieTeach Online Registration

Course Registration Form

MommieTeach Online Courses for Homeschooled & School-Aged Children

Grades 2-12

Complete the registration in it's entirety. Upon receipt of your completed registration, you will receive a confirmation email containing the classroom webclass and your unique login access codes, as well as a New Student Welcome Packet with the Website User Guide.

Additionally, I will contact you to setup an orientation appointment before starting your class to familarize you with navigating the webclass and answering any questions you may have.

IMPORTANT: You MUST provide a valid email address and contact phone number.

We look forward to having you join the MommieTeach online family!

Student Information

Last Name*

First Name*

M.I.

Student's Email Address*

Birth Date *

MonthDayYear

Gender

Parent's Name (applicable if student is under 18)

First NameLast Name

Parent's Email Address (Required for Billing & Point of Contact)*

Entry Year

Semester

Have you previously applied to or attended any of my classes?

YesNo

If yes, what year?

Current Residence Information

Street Address

Street Address Line 2

City

Current courses being offered. Choose from the options on the right. Indicate the quantity you are purchasing and the system will total your purchase. Paypal is the preferred method of payment (No Paypal account required).*

Reading Comprehension Grades 2-5$29.00

Reading Comprehension Grades 6-8$49.00

Reading Comprehension Grades 9-12$69.00

Math Review Grades 2-5 $29.00

Math Review Grades 6-8$59.00

Math Review Grades 9-12$79.00

Pre-Algebra Grades 6-9$69.00

Algebra I Grades 9-12$89.00

Geometry Grades 8-10$79.00

Writing Grades 5-7$49.00

Writing Grades 8-10$69.00

Writing Grades 10-12$89.00

Enter coupon

Total $0.00

State

Zip Code

Home Phone Number

Cell Phone Number

Primary Residence Information (if different from above)

Please indicate your status to receive a discount (if eligible) Enter the coupon code to apply the discount.

Early Bird Registration Discount (Expires 8/1/2016) 10%Family Enrollment Discount 12%Military Family Discount 15%

Notes

Please inform me of any other vital information you think I may need to know regarding special requests or needs you may require. Questions? Call me at (877) 669-0392 or (540) 750-4515. Thank you.

Registration No. (enter any combination of 4-digits.*

Registration Date

MonthDayYear

TimeStamp

:HourMinutesAM/PM Option

Special Discounts