Discover Learning Center Registration Form for courses in fall 2017

http://www.discoverlearningcenterva.com/

Student Name: ______Grade: _____ Parent/Guardian: ______

Address: ______

Phone (Home/Cell/Emergency): ______

Parent Email: ______Student E-mail______

Class / Schedule / Location / Tuition / Register
TJ prep-- Reading/Science & Math, SIS/ Essay Writing / Saturday 8:30am to 11:30am / 503 Carlisle Dr., Herndon, room 125 / $1,298.00 / full
TJ prep-- Reading/Science & Math, SIS/ Essay Writing / Sunday 8:30am to 11:30am / 503 Carlisle Dr., Herndon, room 125 / $1,298.00 / full
TJ prep-- Reading/Science & Math, SIS/ Essay Writing / Sunday 9:30am to 12:30pm / 503 Carlisle Dr., Herndon, room 125 / $1,298.00
7th Grade English Language/Writing / Saturday 7:00pm to 9:00pm / 503 Carlisle Dr., Herndon, room 125 / $698.00
6th Grade English Language/Writing / Saturday 11:30am to 1:30pm / 503 Carlisle Dr., Herndon, room 125 / $678.00
5th Grade English Language/Writing / Saturday 1:30pm to 3:30pm / 503 Carlisle Dr., Herndon, room 125 / $678.00
4th Grade English Language/Writing / Saturday 3:30pm to 5:00pm / 503 Carlisle Dr., Herndon, room 125 / $508.00
3rd Grade English Language/Writing / Saturday 5:00 to 6:30pm / 503 Carlisle Dr., Herndon, room 125 / $508.00
7th Grade Geometry / Sunday 5:30pm to 7:30pm / 503 Carlisle Dr., Herndon, room 125 / $698.00
3rd grade math / Sunday 11:30am to 12:30pm / 503 Carlisle Dr., Herndon, room 250 / $338.00
4th grade math / Sunday 12:30am to 1:30pm / 503 Carlisle Dr., Herndon, room 250 / $338.00
6th Grade Algebra 1/Iowa Algebra Aptitude Test (IAAT) practice / Sunday 5:30pm to 7:30pm / 503 Carlisle Dr., Herndon, room 250 / $678.00
Middle school Chemistry / Saturday 3:30pm to 5:30pm / 503 Carlisle Dr., Herndon, room 250 / $678.00
SAT English / Saturday 7:00pm to 9:00pm
Sunday 7:00pm to 9:00pm / 503 Carlisle Dr., Herndon, room 250 / $998.00
SAT Math / Saturday 5:00pm to 7:00pm / 503 Carlisle Dr., Herndon, room 250 / $598.00
5th Grade Pre-Algebra/Iowa Algebra Aptitude Test (IAAT) / Friday 7:00pm to 9:00pm / 503 Carlisle Dr., Herndon, room 250 / $678.00
Middle school Biology / Friday 7:00pm to 9:00pm / 3901 Fair Ridge Dr. Fairfax / $678.00
Middle school Physics / Friday 7:00pm to 9:00pm / 3901 Fair Ridge Dr. Fairfax / $678.00

*Note: please see all the details at http://www.discoverlearningcenterva.com/. The schedule and location may be changed due to the best interest.

Registration fee for fall courses: $30 per student, per course. It is non-refundable. We waive your registration fee if you register any courses before August 10th, 2017

Total payment: $ ______

Refund Policy: A full payment will reserve a seat in the selected course. A full refund will be issued if refund request is made at least four weeks before the beginning of the course, a $30 Registration fee will be charged. If a refund request is made within two weeks prior to the beginning of the course, 30% of the tuition will be charged and a $30 Registration fee will be charged. There will be no refund after the course starts. A family may elect to receive a credit instead of a refund. This credit will be in the full amount of the fee paid. Registration fee is not refundable.

PARENTAL RELEASE AND CONSENT FOR MEDICAL TREATMENT

My child is enrolled in Discover Learning Center. I hereby release Discover Learning Center and its Director, staffs and teachers from any and all liabilities for injuries to my child or damage property of my child due to activities outside classroom. I accept the full risk and responsibility for any damage or injury.

I, the undersigned, am one of the parents of the minor named above. I know that I may not be available to personally authorize medical, dental, surgical care and hospitalization for said minor.

I hereby give my consent and authorization for any emergency diagnostic procedure, medical, dental, surgical care and hospitalization that any health care provider so determined as advisable, in the best judgment of said health care provider including, but not limited to, any physician, dentist or hospital personnel providing health care to the minor. I agree to be responsible for the cost of the emergency medical treatment.

______

Parent Signature Date

Please make check payable to: Discover Learning Center

Mail to: Discover Learning Center, P.O. Box 386, Great Falls, VA 22066

A confirmation email will be sent upon receipt of this registration form and payment.

Contact: , Phone: (703) 856-7057 http://www.discoverlearningcenterva.com/