The LeBlanc Center for Learning Waiting List
New Student Registration Form
Email address *
Child's First Name *
Your answer
Child's Middle Name
Your answer
Child's Last Name *
Your answer
Child's Home Phone Number *
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
Gender: *
Mother's Name (First & Last Name) *
Your answer
Mother's Contact Email *
Enter "none" if not available however one email address is required for acceptance.
Your answer
Mother's Cell Phone Number *
Your answer
Father's Name (First & Last Name) *
Your answer
Father's Contact Email *
Enter "none" if not available however one email address is required for acceptance.
Your answer
Father's Cell Phone Number *
Your answer
Physical Home Address (Street, City, State, Zip) *
Your answer
Mailing Address (Street, City, State, Zip) *
Your answer
Requested Days of Week *
You may select only one of the following choices.
Additional Notes/Information (if applicable)
Your answer
ATTENTION: Registration Fee
The Center is full for 2019-2020. Your child has been placed on the waiting list. You will be contacted once a spot becomes available.

A Registration fee of $125.00 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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