Virtual JEI Classroom Registration

Virtual JEI Classroom Registration
Student Information
First Child

First NameLast Name
Second Child

First NameLast Name
First Child's Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Second Child's Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current School
Grade in Sept 2022 (First child)
Grade in Sept 2022 (Second child)
Special Medical, Physical or Emotional Needs
Parent Information
Parent Name

PrefixFirst NameLast Name
Cell Number

Area CodePhone Number
Work Number

Area CodePhone Number
E-mail
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Consent
Program of interest
JEI Programs (click all that applies)
Terms & Conditions
Please click yes if you WILL give permission: I consent to have my child, named above, participate in Virtual JEI Classroom via Zoom sessions through an online platform. In order to reduce the risk of spreading COVID-19 and comply with government recommended restrictions, I understand that JEI Learning Center has temporarily modified its program to provide educational services through an online platform. I understand that classes may be recorded for internal quality assurance purposes and will not be shared with outside parties.
We occasionally take pictures of the kids in action with the materials or doing other activities for our website, and various Social Media platforms. We hope to use these to keep parents up to date on the happenings at the center.
How did you find us?
If you were referred by a friend please let us know who, so we can thank them!
Parent Signature
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