Winning in Math Registration Form / 6th - College
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?

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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: *

Workshop date for which student is registering:
How did you hear about
Total Learning Concepts?:
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Workshop Fee: $215 + $15 materials
Course Length: 4 - 4.5 hours


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