Skills for School Success Registration Form Please provide the following contact information: Today's Date: * Student's Name: * Parent's Names: * Street Address * Address (cont.) City * State/Province * Zip/Postal Code * Parent(s) Work Phone * Home Phone * E-mail * School Attending: * Grade: Student's Academic Strengths: * Student's Academic Weaknesses: * Does the student have any learning differences about which we should be aware? Yes No If so, please explain: Choose the days and times that are the most convenient: Monday Afternoon Monday Evening Tuesday Afternoon Tuesday Evening Wednesday Afternoon Wednesday Evening Thursday Afternoon Thursday Evening Saturday Morning Saturday Afternoon Sunday Afternoon Class start date for which student is registering: How did you hear about Total Learning Concepts?: * RESET
