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.)
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?

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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:
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Total Learning Concepts?:

Workshop Fee: $140 + $15 materials
Course Length: 4 - 4.5 hours

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