Registration Forms

Child's Name:

First Last

Gender:

Phone #:

Child's Age:

School Name:

Grade in Fall:

Home Address:

Street Address Address Line 2 City State ZIP Code

Date of Birth:

Mother's name:

First Last

Email

Phone

Father's name:

First Last

Email

Phone

Select session choices:

Check your preferred day

Please indicate all time slots your child has available

Preferred times:

Additional dates & times may be available upon request

Release Form*

I grant permission for my child’s photo to be shared on our online sites.

Reading Level, Goals & Concerns:

Reading Club Tuition is Due Each Month in Advance

Signature of Parent*

Please print your name as replacement for electronic signature.

Date*