*First Name: Middle Name: *Last Name:
*Birth Date: --Select Month-- January February March April May June July August September October November December --Select Day-- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 , --Select Year-- 1989 and before 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Age: Select One 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19+ Gender: Male Female

*Current Grade: *School Currently Attending: *School Phone (include Area Code):
*Teacher:

*Student's Street Address: *City: *State: *Zip Code:
*Home Phone (include Area Code):

Mother's First Name: Mother's Last Name:
Mother's Occupation:
Employer or Business Name: Employer Phone #(including Area Code):

Mother's Cell Phone #(including Area Code): email:

Father's First Name: Father's Last Name:
Father's Occupation:
Employer or Business Name: Employer Phone #(including Area Code):

Father's Cell Phone #(including Area Code): email:

Registration fees are $25.00 per student. All registration fees are non-refundable.

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 monthly 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 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.

*Child Resides with: Both Parents Mother Father Other

Please List an emergency contact in the event we cannot reach you:
*Emergency Contact Person: *Relation to Child:
*Emergency Phone Number (including Area Code):

Please list any additional information you feel may be helpful in assisting your child with academic achievement.

For which *location are you registering? --Please Select One-- Houma Thibodaux--North Canal

*Program: --Please Select One-- 1 hour Daily Group Session $125 per child per MONTH 1.5 hour Daily Group Session $175 per child per MONTH 2 hour Daily Group Session $200 per child per MONTH 1 hour Private Tutoring by appointment $35 per hour Reading Clinic (15 Sessions-$600) Math Clinic (15 Sessions-$600) Reading Horizons (course only $150 per year) Power Speak (course only $250 per year)

Monthly tuition is due on the first of each month. We are now offering monthly autodraft. If you would like your monthly payment to be deducted automatically on the first of the month, please fill out the account information below.

If autodraft is preferred:
Please enter the following information for auto draft payments (to be deducted on the first of every month):
Card type: --Please Select One-- Visa MasterCard Discover Card #: Expiration Date:
Cardholder's Name: Cardholder's zip:
~OR~
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 auto-draft when: customer contacts us.

Private Tutoring is paid at the time of service.

Please complete one form for each child you are enrolling.

*Email Registration Confirmation to:

Active Inactive

Submit Date: