Elementary Study Strategies Registration Form

Please provide the following contact information:

Today's Date: *
Student's Name: *
Parent's Names: *
Street Address *
Address (cont.)
City *
State/Province *
Zip/Postal Code *
Parent(s) Work Phone *
Home Phone *
E-mail *

School Attending: *
Student's Academic Strengths: *
Student's Academic Weaknesses: *

Does the student have any learning differences about which we should be aware?

Yes No

If so, please explain:

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

Class start date for which student is registering:
How did you hear about Total Learning Concepts?: *