Winning in Math 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:
Workshop date for which student is registering:
How did you hear about
Total Learning Concepts?:

Workshop Fee: $225
(1/2 off for students on a regular math tutorial schedule)
Workshop Length: 4 hours
$65 New Student Enrollment Fee
$35 Returning Student Fee

To hold a seat in our course, a $50 deposit is required, plus new student enrollment or returning fee, if applicable.