ABAKidz – August 2017 – Registration Form

Please complete the form below.

Student Information

Student Name
Birth Date
Home Address
Home Phone
Email Address
Parent 1 / Guardian
Work Phone
Cell Phone
Parent 2 / Guardian
Work Phone
Cell Phone
Emergency contact: (Name)

Credit Card Information

Credit Card
Expiration Date
Postal Code

Register for ABAKidz Program Below

Monday & Wednesday 3:15pm – 4:15pm

Meeting Dates: August 7, 9, 14, 16, 21, 23, 28 & 30th.

Program Cost $200.00 (New Students to the Program add $75 materials fee)

  • I hereby enroll the child named above and agree to ALL terms and conditions outlining the requirements of the ABAKidz Summer Program. Enrollment is for the time specified.
  • I grant to Leap Tutoring Academy/ABAKidz and to its employees and representatives the right to photograph my child and to use these photographs or video recordings for print or electronic publishing.
  • Once registration/payment is made, no refunds will be issued.

I have read the above statement, and the terms and conditions listed, and agree to all terms indicated.

By typing my name I agree to the above with my digital signature.