Public School Companion Program Registration

Student's Name *

First

Last

Date of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Cell Phone Number *

Grade Entering in Fall 2020 *

Gender *

Male Female

School Attending Fall 2020 *

Parent's Information

Parent or Guardian *

First

Last

Relation to Student *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Parent or Guardian #2 *

First

Last

Relation to Student *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Does the student have any physical, social or learning needs that we should know about? *

Monday Sessions

Choose the session you would like to attend at the Academy *

Monday 9am-11am Monday 11:15am-1:15pm Monday 2:00pm-4:00pm

Tuesday through Friday Sessions

Email *

Place of Employment *

Occupation *

Cell Phone Number *

Additional Phone Number *

Email *

Place of Employment *

Occupation *

Cell Phone Number *

Additional Phone Number *

Please list the courses your student is enrolled in. *

Please note: space is limited due to social distancing guidelines. All slots will be filled on a first-come, first-served basis. Those enrolling in the full K12 Academic Program will be given priority.

There is a $25 non-refundable application fee is due with this application. Please provide us with your credit card information:

Name as it appears on your card *

First

Last

Credit Card Number *

Expiration Date *

CVV *

Number of sessions *

One Monday session/week $200/month One half day session/week $210/month Two half day sessions/week $420/month Three half day sessions/week $588/mon Four half day sessions/week $784/month One full day session/week $420/month Two full day sessions per/week $784/month Three full day sessions/week $1092/month Four full day sessions/week $1344/month

YOUR CART