Services
Which services are you registering for? (check all that apply)
   Private Tutoring   Other Programs (if other please list )

Parent Last Name
Parent First Name
Parent Preferred/Nickname
E-Mail Address
 
Home Telephone Number :
Work Telephone Number : Make this the primary contact number
Cell Phone Number : Make this the primary contact number

Student Last Name
Student First Name
Student Preferred/Nickname
E-Mail Address
 
Home Telephone Number :
Cell Phone Number :
Student Birthdate
 
Grade
High School
   
Address (Number and Street)
City State Zip Code
Current Semester GPA :
Cumulative GPA :
Is the student planing on attending College?
If Yes, College(s) is he/she considering :
 
Is the student trying to qualify for Bright Futures?
 
Has the student taken the SAT before?
if Yes, List Date(s) and Scores :
Writing
Critical Reading Math Cumulative
Writing
Critical Reading Math Cumulative
Writing
Critical Reading Math Cumulative
 
Please provide details of the students current class schedule
Class One :
Class Two :
Class Three :
Class Four :
Class Five :
Class Six :
   
Please provide a copy of the students High School Transcripts. Click on the "browse" button to locate the file on your computer :

Primary Emergency Contact :

Name   Relationship to Student :
     
Phone Number(s) :    

Secondary Emergency Contact:

Name   Relationship to Student :
     
Phone Number(s) :    

 

KITCHEN
Do you give your child permission to purchase drinks, snacks and food from the Knowledge Laboratory Kitchen?
YES (Please Initial One)
 
If Yes, do you give your child permission to add purchases to your account?
YES NO (Please Initial One)
 
Does the student have any food allergies or restrictions we should be aware of?
YES NO (Please Initial One)
If Yes, Please List
 
APPOINTMENTS
Do you give your child permission to schedule and cancel tutoring appointments? If Yes, those charges will be automatically added to your account.
YES     NO (Please Initial One)
 
CANCELLATION POLICY :
Please cancel scheduled appointments with as much advanced notice as possible. Cancellations or changes made at least 48 hours in advance will have no charge. Cancellations or changes made between 48 and 24 hours will be charged a $25 cancellation fee. Cancellations or changes made less than 24 hours prior will incur the full fee. No Shows will be billed the full fee.
Parent Signature :
 

I will be paying via:

If you will be paying via the Checkout Page on our website, please 
click on the Pay Here link on the bottom left of the page after 
submitting this registration form.


How did you hear about the Knowledge Laboratory? If you were refered by a current client, please include their full name so we can give them a credit.