*First Name: *Last Name: *Birth Date (MM/DD/YYYY): Age:
Gender: Male Female *Current Grade: *Current School Attending: *Child Resides With:

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

Parent/Guardian: Home Phone (including area code):
Cell Phone (including area code)#: email:

All registration fees are non-refundable. Registration fees are $25.00 per student. For current eLearning Students, the enrichment registration fee is included in the original registration fee.

Private Lessons (to be scheduled with Instructor):
Piano: Kay Dugruise
Violin: Charles Brenner
Flute: Alison Dempster
Tennis: El-Fadel Ningbinnin
Guitar: Evan Robichaux

If auto draft is selected as the payment type, complete the Payment Information section below. Upon receiving your first month's payment, we will automatically bill your credit card or bank account for tuition 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 completing the information below, I authorize eLearning Center LLC to automatically bill the card or account listed below as specified.

*Payment type: Monthly auto draft Pay in Full per Semester

Please enter the following information for auto draft payments (to be deducted on the first of every month):

Credit Card Info:
Card type: --Please Select One-- Visa MasterCard Discover Card #: Expiration Date:
Cardholder's Name: Cardholder's zip:
~OR~
Bank Account Info:
Type of account: --Please Select One-- Checking Savings Routing Number: Account Number:
Auto-draft start month: --Please Select One-- January February March April May June July August September October November December end month: --Please Select One-- January February March April May June July August September October November December

*Parent Login email:

Active Inactive Submit Date: