The Successful Student Class
REGISTRATION FORM
Today’s Date:
Parent/Guardian’s Full Name:
STUDENT’S INFORMATION
Student’s Last Name:
First:
Elementary School:
Middle Initial:
Student’s Age:
Sex:
Address:
Home Phone No.:
Parent/Guardian’s Cell Phone No.:
Parent/Guardian’s Email Address:
Please list three skills below that you would like your child to work on the most during this class:
1.
2.
3.
PLEASE CIRCLE YOUR METHOD OF
PAYMENT:
CHECK $110.00
*MADE OUT TO BRIDGET FRIEDMAN
*Payment is due the first day of your
child’s class.
CASH $110.00
*PLACED IN ENVELOPE LABELED WITH
“SUCCESSFUL STUDENT CLASS” AND
THE CHILD’S NAME
Please circle the session you would like your child to attend:
Session One
July 18-20
Session Two
August 16-18
IN CASE OF EMERGENCY
Name of Contact Person:
Relationship to student:
Home phone no.:
Cell phone no.:
I understand that I am responsible for transportation to and from this class. Also, I am responsible for payment due on
the first day of the session my child attends. If I would like to cancel my registration, I may do so by sending an email
up to two weeks before my session begins. If my child misses a day of the course, I may reach out to Bridget Friedman
and she can provide a make-up session, if needed.
Parent/Guardian signature
Date
Please describe below how you heard about this course?