New Student Entry Form-Treasure Coast FL

New Student Entry Form
Contact
Primary Contact (Parent/Guardian Full Name)*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Secondary Contact (Parent/Guardian Full Name)

First NameLast Name
Secondary Contact Phone Number
Please enter a valid phone number.
Secondary Contact Email
example@example.com
Student Name*
Birthdate

MonthDayYear
High School
Graduation Year*
Student Phone Number
Please enter a valid phone number.
Student Email
example@example.com
Zip Code - Student Residence*
Recruitment
How did you hear about Class 101?*

ReferralACT/SAT/PSAT ClassSocial MediaPrint MailingWebsiteEventOther
If referral, who referred you ?
(Full Name)
If event, what event ?
(College Fair/Seminar/Webinar)
If other, please provide details?
(School Sign/Location, Walk-in)
Services
Current Grade*

7th8th9th10th11th12th
Package Purchased*

Full College PlanningACT/SAT/PSAT ClassExtra Package
If Extra Package is purchased, please provide which:
(Fill in blank: Athletic Recruiting, Discovering Careers, Military, Performing Arts, or Additional Hours)
Amount of Services
Total Amount of Services*
Additional Notes (ie - Discounts or Special Terms)
Pay In FullInstallment Plan (Full college planning only)
Down payment amount:
Balance after deposit:
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Monthly payments will occur on the blanks day of each month for blank months.
Monthly payment amount
If a payment is not received within 60 days of its due date, Class 101 reserves the right to suspend services until the account is brought current, or Class 101 may terminate services completely without providing any refund.

Please note: any appointment missed or canceled without 24-hour notice will result in a $50.00 charge.
Payment Agreement
Payment Type*

Cash/CheckMobile Payment AppCredit CardACH Payment (e-check/automatic check/debit)
I, blanks, parent of blank agree to the payment terms as outlined above. For ACH Payments, by signing below, I authorize Class 101 to make one-time or regularly scheduled charges to my bank account. By signing this form, I give Class 101 permission to debit my account for the amount indicated for each billing period until the designated expiration date. I agree that no prior notification will be provided unless the date or amount changes, in which case, I will receive notice from Class 101 at least 10 days prior to the payment being collected. I understand this authorization will remain in effect until I cancel it in writing, and I agree to notify Class 101, in writing, of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be withdrawn from my account by the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF), I understand that Class 101 may attempt to process the charge again within 30 days, and I agree to an additional $50 charge for rejected attempts. These charges will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.
Payor Full Name:

First NameLast Name
Signature of Payor:

Clear
If you are paying by ACH, credit card, or setting up an installment plan, once this form is submitted, please contact Class 101 to provide your payment information 772-247-2716.
Terms & Approval
Using photos of students in our communications, website, print media, and social media sites fosters a sense of achievement and a greater sense of community. Students involved in Class 101 achieve remarkable academic accomplishments throughout the year. There may be opportunities for positive publicity related to the accomplishment of individual students with test scores, scholarships, events, honors, awards and other forms of recognition. Throughout the year, we may take photographs of students, audio/videotape students or interview students for stories related to their success.
YES, I hereby grant Class 101, Inc. permission to use my child’s likeness and voice in photographs, video recordings or electronic images, without payment or any other consideration, and waive any rights to publicity or rights of privacy in these images. I hereby irrevocably authorize Class 101 to edit, alter,copy, exhibit, publish or distribute these images for any lawful purpose.NO, I hereby opt-out from my child’s work or likeness to appear publicly in photographs, audio/video, and or interviews.
Student Name*
Parent/Guardian Name
Parent/Guardian Signature:*

Clear
Date*

MonthDayYear
Date
*Students 18 years of age or older may sign this release for themselves.
Should be Empty:

New Student Entry Form

Contact

Recruitment

Services

Amount of Services

Payment Agreement

Terms & Approval