REGISTRATION
Level 1 Services

BOLD fields with an asterisk (*) denotes required fields. You can leave any field blank, except the required fields!

Student Information

*First Name: *Last Name: *Birth Date: , Age:
Gender: *Current Grade: *Last School Attended: *Child Resides With:

*Address: *City: *State: *Zip Code:
*Home Phone (including area code):

Parent Information

Parent/Guardian: Home Phone (including area code):
Cell Phone (including area code):
*Email Registration Confirmation to: *Password:

I agree that the eLearning curriculum package that I purchase will be used solely by the child I am registering and will not be reproduced without the written consent of eLearning's administration. I agree that I will not share my child's password with anyone.

Enjoy the convenience of auto draft simply by completing the Payment Information section below. Upon receiving your first month's payment, we will automatically bill your credit card or bank account for $50 on the first of each month and your total charges will appear on your monthly credit card or bank statement. You may cancel this automatic billing authorization at any time by contacting us. By checking the box below, I authorize eLearning Center LLC to automatically bill the card or account listed below as specified.

* I agree to the terms above.

Program Options

If you are associcated with one of our centers, please select one from the drop-down list:

If you were referred by someone, please enter the name here:

*eLearning Curriculum: Personalized, web based lessons covering language arts, math, science, social studies, and the arts for grades K-12. Students may enroll in multiple classes for one low monthly fee: $50 per month by automatic draft (on the first of the month) .

Please indicate your choice of grade level for each subject below:
(if unsure, indicate in the comment selection below that help is needed)
Math:
Language Arts:
Science:
Social Studies:
Science/Social Studies Projects:
Art/Music/Health:
High School Elective #1:
High School Elective #2:

Check all that are needed:
Preschool/Playbox
Typing
Reading Comprehension
Math Fluency

What month would you like to begin:

Comments or Requests:

Payment Information

Please note: If you are registering after the 21st of any month, the current month's payment is due at the time of registration and your auto draft will also be processed on the first of the following month. If you would prefer to wait until the first of the following month to begin, please select the month you would like to begin above, pay for that month, and enter the next month as your AUTODRAFT start date BELOW.

Please enter either the credit card OR bank account information for auto draft payments (to be deducted on the first of every month):
Card type: Card #: Expiration Date:
Cardholder's Name: Cardholder's zip:
~OR~
Type of account: Routing Number: Account Number:

Once this page is submitted, you will be taken to our shopping cart to pay for your first month. You may be required to create an account in the shopping cart.

Auto-draft start month: End auto-draft when: customer contacts us.

For Office Use Only


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