Application for Enrollment
Thank you for your interest in Bucks Learning Cooperative summer classes.

There is a three step process to register:
1. Complete and submit this online form
2. Print and complete this waiver form: goo.gl/3rhFzJ
3. Mail completed waiver form and payment to:

Bucks Learning Cooperative
315 W Maple Ave.
Langhorne, PA 19047

Information contained within this application will only ever be seen by staff of Bucks Learning Cooperative (BLC).

Email address *
What class(es) will your child be attending? *
Required
Member (Child/Teen) Information
All info provided on this page pertains to the youth applicant(s).
Full Name Child/Teen *
Your answer
Date of Birth Child/Teen *
MM
/
DD
/
YYYY
Address of Child/Teen *
Your answer
Personal gender pronoun to be used when referring to your child (“he/him,” “she/her,” “they/them,” etc.) *
Parent/Guardian Information
All info provided on this page pertains to the parent(s)/Guardian of the youth applicant.
Parent/Guardian Name(s) *
Your answer
Parent/Guardian Address(es) *
Your answer
Parent/Guardian Cell Phone Number(s) *
Your answer
Payment Information
All info provided on this page pertains to the youth applicant(s).
Check number of classes that your child will be attending *
Required
I agree to make a full payment with check or cash to Bucks Learning Cooperative no later than two weeks after I register my child for a summer session. For late registration, payment must be submitted at the start of the first class. Sorry, we cannot offer refunds after June 8, 2018. *
Required
Additional information you would like us to have
How did you hear about the BLC Summer Program? *
Required
A copy of your responses will be emailed to the address you provided.
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