Registration

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Parent / Guardian Name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.
Area Code
Phone Number
3
Parent / Guardian E-mail* This field is required.
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
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Nigeria
Niue
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Poland
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eSwatini
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Vietnam
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Other
Country
5
Student Name* This field is required.
First Name
Last Name
6
Student Birthday
Date
Month
Day
Year
7
Does your child has any allergies, or special needs requirements? If YES, please explain below so we can better serve your child.
Huge
Large
Normal
Small
Ok
Ok
8
1st Session Courses - Fridays: 9:30am-10:25am(E)=Elementary (M)=Middle School (H)=High School
None
(E) US Geography: Fun with 50 States Instructor: Mrs. Lisa Heilenman Supply Fee: $25.00 Monthly Cost: $25.00
(E)(M) Time Travelers: World War II (1st Semester) Instructor: Mrs. Laura Lombardo Supply Fee: $25.00 Monthly Cost: $25.00
(M)(H) Project Invention! Instructor: Mrs. Lisa Sierra-Davidson Supply Fee: 25.00 $ Monthly Cost: $30.00
FULL - WAITING LIST (H) Introduction to Law Instructor: Mrs. Tracy Gisselquist Supply Fee: $10.00 Monthly Cost: $25.00
Study Hall
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2nd Session Courses - Fridays: 10:30am-11:25am(E)=Elementary (M)=Middle School (H)=High School
None
(E) Mrs. Carina's Story & Art Time (K-4th) -1st Semester Instructor: Mrs. Carina Wheat Supply Fee: $25.00 Monthly Cost: $20.00
(E) SMART Class: Fun with Science, Math and Art (2nd-5th) -1st Semester Instructor: Mrs. Lisa Heilenman Supply Fee: $ 25.00 Monthly Cost: $25.00
(M) Electricity with Snap Circuits - 1st Semester Instructor: Mr. Alan Lombardo Supply Fee: $35.00 Monthly Cost: $30.00
(M)(H) Algebra 1 Instructor: Mrs. Tracy Gisselquist Supply Fee: $20.00 Monthly Cost: $25.00
(H) Introduction to Social Science Instructor: Mrs. Tiemens Supply Fee: $25.00 Monthly Cost: $30.00
Study Hall
10
3rd Session Courses - Fridays: 12:30pm-1:25pm(E)=Elementary (M)=Middle School (H)=High School
None
(E) Let's Learn and Play! (K-3rd) - 1st Semester Instructor: Mrs. Dena Robert Supply Fee: $10.00 Monthly Cost: $10.00
(E) WriteShop Junior (3rd-5th) - 1st Semester Instructor: Mrs. Lisa Heilenman Supply Fee: $20.00 Monthly Cost: $20.00
(M) Focus on Middle School Biology - 1st Semester Instructor: Mrs. Laura Lombardo Supply Fee: $30.00 Monthly Cost: $30.00
(M)(H) Where in the World in Carmen Sandiego? (1st Semester) Instructor: Mrs. Laurie Tiemens Supply Fee: $25.00 Monthly Cost: $30.00
(H) Oh Freedom! A Conscious U.S History Instructor: Mrs. Lisa Sierra-Davidson Supply Fee: $25.00 Monthly Cost: $30.00
Study Hall
11
4th Session Courses - Fridays: 1:30pm-2:30pm(E)=Elementary (M)=Middle School (H)=High School
None
(E) First LEGO League Jr. Instructor: Mrs. Tracy Gisselquist Supply Fee: $50.00 Monthly Cost: $10.00
(E)(M)(H) HOB Sing-Along Instructor: Mrs. Lisa Heilenman Supply Fee: $O Monthly Cost: $20.00
(E)(M)(H) Yoga and Mindfulness Instructor: Mrs. Lisa Sierra-Davidson Supply Fee: $25.00 Monthly Cost: $30.00
FULL - WAITING LIST (M)(H) Art Appreciation: A Walk in Their Shoes (8th-12th) Instructor: Mrs. Laura Lombardo Supply Fee: $30.00 Monthly Cost: $35.00
Study Hall
12
Tuesday High School Class Options* This field is required.All Tuesday classes are High School Level..
None
Session 1: 10:30am-11:30am Latin 1 (Full Year) Supply Fee: $15.00 Monthly Cost: $25.00
Session 2: 11:35pm-12:35pm High School Biology & Labs (Full Year) Supply Fee: $50.00 Monthly Cost: $30.00
Session 3: 1:00pm-2:00pm Painless Poetry & Creative Writing (Full Year) Supply Fee: $15.00 Monthly Cost: $25.00
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I understand that we are a volunteer run co-op. As such, we are unpaid volunteers, so everyone needs to help in some way or another. I will contribute to the group by providing the following assistance.* This field is required.Please select at least 1 way you will help HOB+ Enrichment Program run smoothly. (YSW) means that younger siblings are welcomed. * Will need to attend occasional HOB+ Enrichment Program meetings.
*Enrichment Class Instructor
Afternoon Clean Up (1x per month)(YSW)
*Special Events Coordinator (Pizza Day, Spirit Day, Parties)(YSW)
*Communications Director (as needed)(YSW)
Morning Set Up (1x per month)
Other
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CHAP MANUAL 2022-2023Please save a copy or print out and read before completing enrollment.
15
I have read and understand the HOB+ Enrichment Program Manual. My family agrees to follow the policies set forth in it.* This field is required.
Yes
No
16
Medical & Liability Release FormPlease print out, fill out and mail to: Laura Lombardo P.O. Box 25 Bealeton, Va. 22712
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I release Homeschoolers of Bealeton (HOB+) and Bealeton Baptist Church (BBC) from any and all liability in case of accident, illness or injury during any activities related to or received during participation in the program or on the property thereof.* This field is required.
Yes
No
18
I understand that I assume all financial responsibility for any treatment and/or injuries sustained by/to my minor while participating in the program, events and activities. I agree to not hold any of the above mentioned groups liable for any costs associated with medical assistance.* This field is required.
Yes
No
19
Signature
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