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 Below

Program Deposit (Week 1)

  • Leap Tutoring reserves the right to dismiss any student whose behavior is disruptive to the program. In such cases, there will be no refund.
  • I grant to Leap Tutoring and to its employees the right to photograph my child and to use these photographs or video recordings for print or electronic publishing.
  • A fully completed medical form MUST be on file in the prior to the student’s first day. Both the parent section and the physician section must be completed.
  • No refunds for the program will be granted.
  • Please submit a separate form for Siblings.

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.