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Today's Date:
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*
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Student's Name:
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*
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Parent's Names:
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*
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Street Address
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*
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Address (cont.)
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City
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*
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State/Province
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*
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Zip/Postal Code
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*
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Parent(s) Work Phone
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*
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Home Phone
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*
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E-mail
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*
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School Attending:
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*
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Grade:
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Student's Academic Strengths:
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*
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Student's Academic Weaknesses:
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*
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Does the student have any learning differences about which we should be aware?
Yes
No
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If so, please explain:
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Choose the days and times that are the most convenient:
Monday Afternoon
Monday Evening
Tuesday Afternoon
Tuesday Evening
Wednesday Afternoon
Wednesday Evening
Thursday Afternoon
Thursday Evening
Saturday Morning
Saturday Afternoon
Sunday Afternoon
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Class start date for which student is registering:
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How did you hear about Total Learning Concepts?:
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*
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