Learning Bee Fall 2010 Registration

Student's First Name

Please enter child's first name.

Student's Last Name

Please enter child's last name.

Student's Birthdate

Please enter your child's birthdate.Please enter date in the format mm/dd/yyyy.

Grade Level in Fall 2010

Please enter your child's grade level in Fall 2010.

Student's School in Fall 2010

Please enter your child's school in Fall 2010

Home Address

Please enter your address.

City

Please enter a city.

State
Please enter your state of residence.

Zip

Please enter your zip code.

Home Phone

Please enter your phone number. Please enter in xxx-xxx-xxxx format.

Mother's Full Name

Please enter mother's name.

Mother's Cell Phone

Please enter mother's cell phone.Please state in xxx-xxx-xxxx format.

Mother's e-mail

Please provide mother's valid email address. Please provide email in xxx@xxx.xxx format.

Father's Full Name

Please enter father's name.

Father's Cell Phone

Please enter father's cell phone.Please state in xxx-xxx-xxxx format.

Father's e-mail

Please provide father's valid email address. Please provide email in xxx@xxx.xxx format.

Emergency Contact Name

Please enter emergency contact's name.

Relationship to Child

Please enter this person's relationship to your child.

Emergency Contact Phone

Please write down phone number in xxx-xxx-xxxx format.Please enter in xxx-xxx-xxxx format.

Name of Other Siblings
attending Learning Bee

I would like to attend Learning Bee After School Enrichment Program:

Frequency

Please select a valid item.

I would also be interested in these enrichment curriculum at Learning Bee:

Academic Enrichment
(check all that apply)

Academic and Creative Writing
Math
Mental Math (Abacus)
Computer Curriculum
Martial Arts
Music
Foreign Language (Spanish)
Foreign Language (French)
Foreign Language (Chinese)
Foreign Language (Hindi)
Public Speaking and Debate
Study Skills
Theater/Drama
Lego Robotics
Others(please write below)

Comments or
Questions