Online Application

INSTRUCTIONS

First, make sure to answer all lines with a red asterisk. The ramifications of an incomplete form could delay the registration process. After submitting the application, parents will receive an email notification. In cases where there is no email, he or she will receive a phone call. If these attempts fail, a letter will be mail out to the parent.

After the Application Process, the next step is the Diagnostic Testing. There is an one time fee of 25 dollars. If you have any problems registering online, please do not hesitate to contact us. Even if your question is not about registration. Feel free to email or phone us.

FAMILY INFORMATION

Mother's Name *
Home No. *
Work No. *
Cell Phone No. *
Address No. 1 *
City/State *
Zip Code *
Father's Name *
Home No. *
Work No. *
Cell Phone No. *
Address No. 2 *
City/State *
Text *

STUDENT INFORMATION

Name *
Age *
Birth Date *
Last Grade Completed *
School Attending *
Name *
Phone No, *
If yes, please explain. *
YesNo
Details *

SERVICES

Please check all services that apply

I want my child to receive the following services. *
Homework HelpTutoring Services

GENERAL INFORMATION

Please check all that apply.

How did you find out about our Services? *
I found out about the Center on the Web.Someone referred the Center to me.I saw a flyer about the Center..I observed kids entering the building.Social Media

Please enter any two digits *Example: 12
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