Student Registration Form :: Notre Dame Learning Center

Download this form as a Microsoft Word file to mail, e-mail, or fax in; or, to send us your information immediately, please use this online form:

Student Information

Name:

Address (STREET, CITY, STATE, and ZIPCODE):

Birthdate (MM/DD/YEAR):

Birthplace (CITY, STATE):

Ethnicity (please click only one):
African American
Asian
Caucasian
Hispanic
Other

School attending Grade

Teacher's name Area needing remediation

Parent/Guardian Information

Name

Relationship to student

Home phone Work phone Cell phone

Emergency Information

Person to notify in case of emergency Relationship:

Emergency phone number:

Payment

I agree to pay the fee of $5.00 at time of registration. This money is used for books and supplies.

Click to send this information or click return to previous page.

FOR OFFICE USE ONLY

Date of registration _________________ Day of Tutoring ________________________________

Time _____________ Name of Tutor ________________________________________________

______ Registration fee of $5.00 paid

Version 11-09-07 | web

Notre Dame Learning Center