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.)
Zip/Postal Code
Parent(s) Work Phone
Home Phone

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: $390
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