Registration Name * First Name Last Name Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country How did you hear about us? Option 1 Option 2 Child's Name * First Name Last Name Child's Age * Grade Level * Does your child have a formal ADHD/Autism or other neurodivergent diagnosis? Yes No Prefer not to disclose Any specific learning needs or accommodations your child may require? Preferred Program Schedule: * Monday & Wednesday (Afternoon) Tuesday & Thursday (Afternoon) Flexible / No Preference Emergency Contact Name: * First Name Last Name Relationship to Child: * Emergency Contact Phone Number: * (###) ### #### Medical Conditions or Allergies: * Please list any medical conditions or allergies we should be aware of. How did you hear about Learning Legends? What goals do you have for your child in this program? * More consistent studying Better grades Increased tools Better focus Social confidence Other I understand that Learning Legends will prioritize my child’s safety and well-being, and I consent to their participation in program activities. I, the undersigned, confirm that all the information provided above is accurate to the best of my knowledge. * Electronic Signature Agreement: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual/handwritten signature and consents to the terms above. You further agree that your typed signature below indicates your intent to submit this registration form and all information contained within it truthfully. Thank you!
