Membership Application

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Member Information

Last Name *

First Name *

Cell Phone (including area code) *

Home Phone (including area code)

Your Email Address *

Mailing Address *

Spouse's Full Name

Spouse's Cell Phone (including area code)

Spouse's Email Address

MLC Teams

One parent member from each MLC family is required to sign up for at least one TEAM for the MLC school year. For more information and to see a list TEAMS and their current members, click on the TEAMS tab of our website. If you are already on a TEAM, simply select your current TEAM below.

Choose your TEAM by selecting one of the following: *

Sharing Your Personal Information

MLC would like to share some of your information with other MLC Members in order to better communicate as a group. MLC will ONLY share your personal information with your permission. If you give us permission, your information will ONLY be shared in the ways described on this form in the following questions:

If MLC were to create a MEMBER DIRECTORY on paper (NOT online) to share with other MLC Members, may we include your Name, Spouse's Name, Children's Name(s), Phone Number(s) and Email Address(es)? (NOTE: Postal Addresses will not be shared.) *

Yes, please include my information in the paper directory.

No, I would like to keep my information confidential.

If MLC were to send an email with your contact information to the other members of your TEAM, may we provide your Name, Phone Number(s) and Email Address(es)? *

Yes, please give my contact information to the other members of my TEAM.

No, I would like to keep my information confidential. (NOTE: Your TEAM will need to be able to contact you throughout the year. If you selected 'NO,' please send an email to MindfulLearningCenter@gmail.com explaining how you intend to communicate with your TEAM.)

Student Information

By filling out this section of the Application Form, you are simply letting us know about the students from your family who plan to attend MLC this year.

Please include children of all ages (0-19) who would be attending MLC.

PLEASE NOTE: THIS IS NOT "CLASS REGISTRATION".
Parents are required to register their students for classes prior to attending.
Class Registration will be available online after AUGUST 1st of each year.

Child #1: First Name, Last Name, Age (after Aug 1) *

Child #1: Student Placement *

Child #2: First Name, Last Name, Age (after Aug 1)

Child #2: Student Placement

Child #3: First Name, Last Name, Age (after Aug 1)

Child #3: Student Placement

Child #4: First Name, Last Name, Age (after Aug 1)

Child #4: Student Placement

Child #5: First Name, Last Name, Age (after Aug 1)

Child #5: Student Placement

Child #6: First Name, Last Name, Age (after Aug 1)

Child #6: Student Placement

Child #7: First Name, Last Name, Age (after Aug 1)

Child #7: Student Placement

Child #8: First Name, Last Name, Age (after Aug 1)

Child #8: Student Placement

Terms and Conditions

By signing this online application, I am requesting that my family participate in activities/events held by Mindful Learning Center. I agree to abide by the policies, rules and expectations as presently listed at MindfulLearningCenter.com or as may subsequently be amended. I understand that if anyone in my family violates the rules, it may jeopardize our participation at Mindful Learning Center and that Mindful Learning Center reserves the right to deny participation to any student or family. I agree to be responsible for the behavior of the children in my charge. Furthermore, in the case of an accident that results in the injury to my children or myself, I agree to hold harmless Mindful Learning Center members or Saint Paul’s Lutheran Church of Council Bluffs for any damages and/or medical care/expenses. I further agree to pay for any item that my child(ren) damage or break while attending Mindful Learning Center activities/events at any venue. By signing this application, I establish that all information is true and correct.

Please check the box below. *

By signing this online application, I agree to the terms and conditions listed above.

Required

Please check the box below. *

By checking this box, I am stating that I have read the Mindful Learning Center's Policies, which can be found here > http://mindfullearningcenter.blogspot.com/p/policies.html

Required

Your Signature (please type your full name) *

Spouse's Signature (please type your full name) *

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