KLC Application Google Form 2021-2022 (part 2)

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Online Application form - please use the below form to enroll your child(ren) into Kaplan Learning Center.
Please complete by 7/19/21 - in order to receive $50 early bird discount for families that pay in full.

Email *

Student First and Last Name *

Date of birth *

YYYY

School Grade *

Name of Secular School *

Student Mobile Number *

Student Email Address *

Pick-up & Medical Forms (please submit via PDF - scan and attach copy) - email to kaplanlearningcenter@gmail.com *

Yes, I will submit the pick-up & medical forms via email

We have a challenge and will be delayed in getting the forms back to you.

Other:

Media Waiver Form (please submit via PDF - scan and attach copy) - email to kaplanlearningcenter@gmail.com *

Yes, I will submit the media waiver form via email

We have a challenge and will be delayed in getting the forms back to you.

Other:

Name of Parent/Guardian #1 *

Name of Parent/Guardian #2 *

Street Address *

City *

State *

Zip Code *

Is the primary residence of student? *

Yes

Other:

Parent / Guardian #1 Occupation *

Parent / Guardian #1 Email Address *

Parent / Guardian #1 Primary Phone Number *

Parent / Guardian #2 Occupation *

Parent / Guardian #2 Email Address *

Parent / Guardian #2 Primary Phone Number *

Emergency Contact #1 Full Name & Phone Number *

Emergency Contact #2 Full Name & Phone Number *

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms