BLC Online Registration Form

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REGISTRATION FORM

* - Required fields

Directions: Please complete this Online Registration Form for BLC programs. If you have any questions or problems completing this form, please call us at 1-800-981-5535.

Today’s Date *

Student Information

This application is for (check all that apply):*

Private Tutoring

Small Group Tutoring

BIFF Motivation and Study Skills

Student Name *

Date of Birth *

Age *

Grade *

School *

Teacher *

Gender *

Male Female

Race (optional)

Black Asian Hispanic/Latino White Other

Areas of Difficulty

Has the student ever repeated a grade? Yes No

If yes, what grade and why?

Is the student currently enrolled in a special needs class? Yes No

Has the student’s hearing been tested recently? Yes No

Results

Has the student’s vision been tested recently? Yes No

Results

Parent/Guardian Information

Parent/Guardian Name *

Home Address *

Apt. #

City *

State *

Zip Code *

Home Phone

Work Phone

Cell Phone

Email *

SCHEDULE (For Private Tutoring Only)

Please select the days and times you would PREFER to schedule the tutorials. We will make every effort to schedule sessions during your preferred times. We hope you understand that this is not always possible.

Fridays and Sundays are only available by special arrangement. Call 1-800-981-5535 for details.

EMERGENCY CONTACT INFORMATION ((In case we cannot reach the Parent.)

Name:

Address:

City

State

Zip Code

Telephone:

Relationship to Student:

Thank you for completing our Online Registration Form. Someone from our office will contact you within 48 hours to finalize arrangements for services to begin.

Please review your answers on this form to check for accuracy. Then click the Submit button below.