Learning and Families Online Registration

Registration

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Welcome to Learning and Families! We are happy you found us! Please complete the following family enrollment form. You will have an opportunity to register for our Co-op classes if you wish. However, if you would like to be a part of our amazing support community only, simply skip the class registration buttons. We look forward to getting to know you this year!

NOTE: a credit/debit card MUST be kept on file, however, you may choose HOW you pay after registering.

* denotes required fields

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

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

Health Insurance Carrier and Policy Number*

Student carry an epi pen?*

Highschooler graduating 2024?*

Do you have a k-5th student?*

Do you have a 6-8th student?*

Do you have a 9-12th student?*

Contact #1

First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email (Required for High School Students)

Grade Level for the 23/24 school year?*

Special Needs/Disabilities

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Shirt Size? Y or A+ size*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email (Required for High School Students)

Grade Level for the 23/24 school year?*

Special Needs/Disabilities

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Shirt Size? Y or A+ size*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email (Required for High School Students)

Grade Level for the 23/24 school year?*

Special Needs/Disabilities

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Shirt Size? Y or A+ size*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email (Required for High School Students)

Grade Level for the 23/24 school year?*

Special Needs/Disabilities

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Shirt Size? Y or A+ size*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email (Required for High School Students)

Grade Level for the 23/24 school year?*

Special Needs/Disabilities

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor*

Shirt Size? Y or A+ size*

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

City

State

Zip*

Registration

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

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

Credit Card

Required Policies

(Show-Hide Details)