Learning Forward Education Center
Education Camps/Aftercare/Club Registration Form
Email address *
Parent/Guardian Name *
Phone Number *
Email Address *
Address *
Place of Employment
Which program are you signing up for?
If you are registering for a holiday camp please indicate the specific camp here.
Child's Name *
Date of Birth *
MM
/
DD
/
YYYY
Grade *
School Name *
Academic Concerns
Allergies/Physical Conditions *
Behavioral/Developmental Challenges (we ask so we can help support your child)
Emergency Contact *
Emergency Contact Phone Number *
Everyone who is allowed to pick up your child *
I give LFE Center permission to use my child's photos for their promotional material (e.g. website, social media, blog, flyer). Your child's photos will not be used for any other purposes outside of marketing material.
Clear selection
Anyone who is NOT allowed to pick up your child
Insurance Company
Family Physician & Phone Number
Hospital Preference
First and Last Name on Billing Credit Card *
Billing Address (if different from address above)
Credit Card Type (card will not be charged until the start date)
Clear selection
Credit Card Number
Expiration Date (mm/yy)
Card Identification Number (3 digits on back of card)
Submit
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