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:	*
Grade:
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?:	*

Contact Information