Elementary Study Strategies Registration Form / 3rd - 5th Grade

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:

To hold a seat in our course, a $50 deposit is required, plus new student enrollment or returning fee, if applicable. Please provide credit card information below:
Name on Card: *
Card Number: *
Expiration Date: *

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?: *

Course Tuition: $215
Course Length: 12 weeks
Text and other printed materials for course: $35

Copyright © 2009 Total Learning Concepts, Inc. All rights reserved.
Revised: April 9, 2011
Copyright © 2015 Total Learning Concepts, Inc. All Rights Reserved