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. 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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Student Enrollment Fee: $65 (not applicable to previously enrolled TLC students)
Workshop Fee: $130 plus $15 materials
Course Length: 4 - 4.5 hours

I understand and agree that:

1. Enrollment shall begin after the new student enrollment fee (if applicable) and a deposit of $50 has been paid to hold a place in the workshop. The balance is due one week prior to the workshop.
2. Workshop fee may be paid by cash, check, or credit card. There is a $25 handling charge on all returned checks.
3. Total Learning Concepts requires a 1 week notice for cancellation of this workshop. With this notice, the missed workshop may be rescheduled and the deposit will be applied to the next workshop. Without this 1 week notice of cancellation, the deposit will not be refunded or credited.
4. The workshop fee is paid one time, however, the student may attend as many times he or she desires within 6 months from when initially attended.
5. Total Learning Concepts is committed to quality education. We will do everything to make sure each student succeeds. However, we accept no responsibility if the student fails to improve his/her course grades in school since we cannot control a student's willingness to do homework or a classroom teacher's quality of work.

I understand and agree to the above.

Yes No

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Copyright © 2009 Total Learning Concepts, Inc. All rights reserved.
Revised: May 11, 2009