Registration Form

Fill out a new form for each child. Once we receive your registration form, we will call you for payment and schedule your child’s diagnostic assessment.

Student's Name*

Date of Birth*

Gender
 Male Female

Current Grade

Name of School

Teacher's Name

Allergies or Health Conditions

Primary Tutoring Location

Select days/hours per week

Tutoring Schedule (Check all that apply)
 Monday (PS 098Q) Tuesday (PS 188Q) Wednesday (PS 098Q) Thursday (PS 188Q) Saturday (PS 188Q)

Snack Pack (Optional Cost: $1.50 per day)

Parent's/Guardian's Name*

Phone Number *

Parent's/Guardian's Address*

Parent's/Guardian's Email

Emergency Contact*

I hereby swear that I am the parent or legal guardian of the listed student above, a minor, to participate in Early Scholars Learning Center and all its programs and activities.
I, the undersigned parent or guardian, do hereby authorize emergency medical services be rendered to my child upon consent of an Early Scholars Learning Center staff member. The purpose of this authorization is to permit my child to receive emergency medical attention when needed while involved in the activities connected with Early Scholars Learning Center programs when I or my emergency contact is unavailable to give such consent. I hereby waive and release Early Scholars Learning Center, The New York City Department of Education, Public School 188Q, Public School 098Q and/or its designers from any and all liability and costs associated with any accidents and emergency care. I further understand that I or my medical insurance carrier will be responsible for any medical expenses arising from said emergency or treatment.
After dismissal, I understand that there is a late pick-up grace period of 5 minutes. Afterward, a late pick-up fee of $15 for every 15 minutes, or a portion thereof, will be assessed. Furthermore, more than two pick-ups after 6 p.m. could result in suspension or termination of my child’s enrollment in the program.
I grant Early Scholars Learning Center the right to take and use photos and videos of the student listed above for promotional purposes.

I understand and agree to pay a cash payment of the sum total of $35 for administration fee if any checks written to Early Scholars Learning Center bounces.*

administration fee if any checks written to Early Scholars Learning Center bounces.*

Today's Date*