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The LeBlanc Center for Learning Registration 2021
New Student Registration Form
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Email *
Child's First Name *
Child's Middle Name
Child's Last Name *
Child's Home Phone Number *
Child's Date of Birth *
MM
/
DD
/
YYYY
Gender: *
Mother's Name (First & Last Name) *
Mother's Contact Email *
Enter "none" if not available however one email address is required for acceptance.
Mother's Cell Phone Number *
Father's Name (First & Last Name) *
Father's Contact Email *
Enter "none" if not available however one email address is required for acceptance.
Father's Cell Phone Number *
Physical Home Address (Street, City, State, Zip) *
Mailing Address (Street, City, State, Zip) *
Requested Days of Week *
You may select only one of the following choices.
Additional Notes/Information (if applicable)
ATTENTION: Registration Fee
A Registration fee of $150.00 is due upon acceptance and is non-refundable. Filling out this form only submits your information but does NOT automatically guarantee acceptance or enrollment. Your registration is NOT confirmed until you receive an acceptance email with instructions AND pay the registration fee in full. All applicants will receive an email within 48 hours of acceptance. The email will contain instructions, payment details, and any additional information required. Thank you.
A copy of your responses will be emailed to the address you provided.
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