Class Registration

Please register for classes below. Make any special requests in the “special requests” field.

Student Name *

First

Last

Date of Birth (MM/DD/YYYY) *

Grade (2018-2019) *

School *

Parent/Guardian Name *

First

Last

Parent/Guardian Email *

Confirm Email

Parent/Guardian Cell Phone *

Parent/Guardian Cell Phone Provider (Verizon, AT&T, etc.) *

Mailing Address (Street, City, State, Zipcode)

Course Enrollment *

Start Date (MM/DD/YYYY)

Special Requests

Please include any requests or important information that you were not able to express in the above fields.

Terms and Conditions *

By clicking this checkbox, I hereby acknowledge and agree to the below terms, conditions, and credit policies of enrollment.

This information will be used to reach the parents/guardians in case of an EMERGENCY situation. Tuition must be paid on or before the program start date. The student must be on time for each class and must have all the required materials prior to arrival.

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Magnet Learning Academy