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? 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:
Workshop date for which student is registering:
How did you hear about Total Learning Concepts?:

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

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