The Little Scholars Application Form

The Little Scholars
2015-2016 REGISTRATION FORM
Child's Name
Date of Birth
School Name/Grade
E-mail
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
PARENT/GUARDIAN INFORMATION
Full Name
First NameLast Name
Cell Phone #
Area CodePhone Number
Alternate Phone #
Area CodePhone Number
Full Name
First NameLast Name
Cell Phone #
Area CodePhone Number
Alternate Phone #
Area CodePhone Number
EMERGENCY CONTACT INFORMATION: Other than Parent/Guardian
Full Name
First NameLast Name
Phone #
Area CodePhone Number
Relation
Full Name
First NameLast Name
Phone #
Area CodePhone Number
Relation
Does your child child have any problems, injuries or allergies that might affect her/him from fully participating in the activities at The Little Scholars? Please Describe and include additional notes to the staff here:
Registration assumes full participation in the ENTIRE semester of classes. You may cancel enrollment by contacting The Little Scholars. A $25 administrative fee will be deducted. There is a $10 late fee if tuition is not received by the 1st of the month and a $25 fee for checks with insufficient funds - unless otherwise arranged.
We are happy to reschedule a class with 24 hours notice. No credits will be offereed for missed classes.
The prices are as stated on the website and will be adjusted accordingly.
I hereby grant permission for my child to attend and participate in The Little Scholars program listed herein & agree to the Terms and Conditions set forth herein. I hereby release and discharge The Lttle Scholars and its employees, and contractors from and against all claims and losses of any tpye arising out of or relating to my child's participation in classes at The Little Scholars location.
I am 18 years of age or older and the parent or legal guardian of the above-named child.
By checking this box, you agree to have read the terms and conditions of our policy*
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