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
Does the student have any learning differences about which we should be aware?
Yes No
Monday Afternoon Monday Evening Tuesday Afternoon Tuesday Evening Wednesday Afternoon Wednesday Evening Thursday Afternoon Thursday Evening Saturday Morning Saturday Afternoon Sunday Afternoon
Course Tuition: $390 Course Length: 12 weeks Text and other printed materials for course: $35