Learning Forward Education Center
Education Camps/Aftercare/Club Registration Form
* Required
Email address
*
Your email
Parent/Guardian Name
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Address
*
Your answer
Place of Employment
Your answer
Which program are you signing up for?
Education Support Full Time
Education Support Part Time
Aftercare
School Holiday Camp
Drop-in/Special Event
Tutoring
Summer Math & Reading Program
Free (Spring Break) Science Fair Camp
Summer Reading Intensive
Summer Math Intensive
Other:
If you are registering for a holiday camp please indicate the specific camp here.
Your answer
Child's Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Grade
*
K
1
2
3
4
5
6
7
8
9-12
School Name
*
Your answer
Academic Concerns
Your answer
Allergies/Physical Conditions
*
Your answer
Behavioral/Developmental Challenges (we ask so we can help support your child)
Your answer
Emergency Contact
*
Your answer
Emergency Contact Phone Number
*
Your answer
Everyone who is allowed to pick up your child
*
Your answer
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.
Yes
No
Clear selection
Anyone who is NOT allowed to pick up your child
Your answer
Insurance Company
Your answer
Family Physician & Phone Number
Your answer
Hospital Preference
Your answer
First and Last Name on Billing Credit Card
*
Your answer
Billing Address (if different from address above)
Your answer
Credit Card Type (card will not be charged until the start date)
Visa
Discover
Mastercard
American Express
Other:
Clear selection
Credit Card Number
Your answer
Expiration Date (mm/yy)
Your answer
Card Identification Number (3 digits on back of card)
Your answer
Send me a copy of my responses.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Learning Forward Education Center.
Report Abuse
Forms
