Primary Contact *

First Name

Last Name

Secondary Contact *

First Name

Last Name

Child's Name *

First Name

Last Name

Child's Birthday *

MM

DD

YYYY

Phone Number *

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Secondary Contact Phone Number

(###)

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What are your child's goals for this program?

Improvement of concentration and attention

Improvement of memory skills

Improvement on standardized tests

Accelerated math learning

Other

How did you hear about us?

Friends/Family

Google

Facebook

Instagram

Flyers

Other

Class Frequency

One hour/week

Two hours/week

Other

Cancellation & Makeup Policy * *

Cancellation: In order to cancel a class and receive a makeup class, you must inform via phone or email to the location’s center manager 24 hours before the start of class. Once your class reservation is cancelled, the class credit will be returned to your account to be used at a future date; the class is not refunded. For students running late: We ask that you call the center to let us know you are on the way. Students who are more than 20 minutes late will not be admitted into class as it is too disruptive. We will do our best to catch the student up to class but there is no guarantee to make up for group activities. For students leaving early: If your child is planning on leaving early, we kindly request that you inform the instructor ahead of time.

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Photo/Video Release *

By signing up, you give us permission to use you and your child's name, photograph, video images, and any other likeness in connection with any marketing promotion without any compensation to you.

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