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Student Registration
Recess Plan-10hrs/week (4 children)
Customer/Parent Contact
Customer/Parent First Name
Email
Customer /Parent Last Name
Phone (xxx-xxx-xxxx)
Street Address
City
State
Zipcode
Home Environment
This information will ensure we make the best Learning Pal match for your family. We'd hate to match you with a Learning Pal that is afraid of your fur baby.
Please select anyof the following that apply to your home environment
Pets
Smokers
Handicap Accessible
Type of Pet (if applicable)
Please provide any additional information you believe a Learning Pal should know prior to visiting your home.
Plan Details/Schedule
Recess Plan-10hrs/week (4 children)
Rate:
$1000/week
Enter the number of weeks you would like to purchase
Desired start date
Learning Pal Gender Preference
Female
Male
No Preference
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Desired days for Learning Pal sessions
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Sessions may be scheduled between the hours of 7am-7pm
Desired Session Start Time
Desired Session End Time
If you desire different session times for different days of the week, please use the space below to write out your customized weekly Learning Pal schedule.
Please provide any additional information you would like us to consider when selecting your Learning Pal
Is this plan being shared with another family?
Yes
No
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Please provide the name (first and last) of the parent/guardian with whom you are sharing this plan
If this plan is being shared please send the link below to the parent/guardian with whom you are sharing the plan. They will be required to complete a registration for their student(s).
https://www.thelearningpal.com/secondary-family-registration
Student #1
Student #1 (First Name)
Date of birth (xx/xx/xxxx)
Student #1 (Last Name)
Student #1 Gender
Female
Male
Non-binary
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Student #1 Grade
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
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Studet Extra-Curricular Interests
STEM
Arts & Crafts
Fitness/Sports
Music
Nature/Gardening
Cooking
Learning Abilities
ESOL/ELL
IEP
Dyslexia
Learnng Styles
Visual
Auditory
Kinesthetic
Verbal
Logical/Mathematical
Social
Solitary
Combination
Student #1 -Allergies/Health Concerns
Student #1-School Attending
(Student #1) Please provide any additional details that would assist the Learning Pal in supporting your student.
Student #2
Student #2 (First Name)
Date of birth (xx/xx/xxxx)
Student #2 (Last Name)
Student #2 Gender
Female
Male
Non-binary
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Student #2 Grade
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
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Studet Extra-Curricular Interests
STEM
Arts & Crafts
Fitness/Sports
Music
Nature/Gardening
Cooking
Learning Abilities
ESOL/ELL
IEP
Dyslexia
Learnng Styles
Visual
Auditory
Kinesthetic
Verbal
Logical/Mathematical
Social
Solitary
Combination
Student #2 -Allergies/Health Concerns
Student #2-School Attending
(Student #2) Please provide any additional details that would assist the Learning Pal in supporting your student.
Student #3
Student #3 (First Name)
Date of birth (xx/xx/xxxx)
Student #3 (Last Name)
Student #3 Gender
Female
Male
Non-binary
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Student #3 Grade
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
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Studet Extra-Curricular Interests
STEM
Arts & Crafts
Fitness/Sports
Music
Nature/Gardening
Cooking
Learning Abilities
ESOL/ELL
IEP
Dyslexia
Learnng Styles
Visual
Auditory
Kinesthetic
Verbal
Logical/Mathematical
Social
Solitary
Combination
Student #3 -Allergies/Health Concerns
Student #3-School Attending
(Student #3) Please provide any additional details that would assist the Learning Pal in supporting your student.
Student #4
Student #4 (First Name)
Date of birth (xx/xx/xxxx)
Student #4 (Last Name)
Student #4 Gender
Female
Male
Non-binary
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Student #4 Grade
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
arrow&v
Studet Extra-Curricular Interests
STEM
Arts & Crafts
Fitness/Sports
Music
Nature/Gardening
Cooking
Learning Abilities
ESOL/ELL
IEP
Dyslexia
Learnng Styles
Visual
Auditory
Kinesthetic
Verbal
Logical/Mathematical
Social
Solitary
Combination
Student #4 -Allergies/Health Concerns
Student #4-School Attending
(Student #4) Please provide any additional details that would assist the Learning Pal in supporting your student.
I have read and agree to The Learning Pal Terms & Conditions. By clicking accept, I am signing this Contract on my own free will and agree to be obligated under its terms. View
Terms & Conditions
I certify that the information I have provided herein is true and accurate and that I am the parent or legal guardian authorized to sign this form, releases and waivers.
I do hereby give permission to The Learning Pal LLC to use my child’s image/likeness on video or a photographic picture of my child on the website (www.thelearningpal.com), newspapers, magazines, television or other mediums used to promote The Learning Pal services, activities and/or for marketing purposes. Usage of this picture may include the use of my child’s first name along with an article or other content about The Learning Pal. I understand that there will be no remuneration for the use of any likeness of my child used for the purposes stated above. At my request, The Learning Pal will provide me with copies of any articles, brochures or mediums (if available) in which my child’s picture or likeness has been used.
I agree to The Learning Pal Cancellation and Refund Policy. View
Policy
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