The Learning Space Online Registration

Registration

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Thank you for your interest in The Learning Space! For quicker registration, please fill out the form below before coming into one of our centres. If you have any questions, feel free to contact us at 905-417-2424.

Your credit card WILL NOT be charged until you formally sign the contract when you first visit.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State/Prov*

Postal Code*

Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell #

Receive Text Message Notifications. By opting in, you agree to receive SMS messages from The Learning Space. Standard message and data rates apply. Reply STOP to opt out

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from The Learning Space. Standard message and data rates apply. Reply STOP to opt out

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from The Learning Space. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from The Learning Space. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Enroll in Classes

Select Class *

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from The Learning Space. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Enroll in Classes

Select Class *

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from The Learning Space. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Enroll in Classes

Select Class *

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell # Receive Text Message Notifications. By opting in, you agree to receive SMS messages from The Learning Space. Standard message and data rates apply. Reply STOP to opt out

Additional Info

Student Email

School*

Grade Level*

Disabilities (Leave blank if NONE)

Special Needs (Leave blank if NONE)

Allergies (Leave blank if NONE)

Enroll in Classes

Select Class *

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

Membership Type

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

Country

City

State/Prov

Postal Code

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Transit # (5-digits)

Institution ID (3-digits)

Account Number

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

Credit Card

eCheck/Bank Draft

Required Policies

(Show-Hide Details)