Child's Name *

First Name

Last Name

1. Parent/Guardian *

First Name

Last Name

Primary Phone Number *

(###)

###

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Days requesting after school services *

Continue with the same schedule as 1st quarter

Monday

Tuesday

Wednesday

Thursday

Friday

No long attending

Please pick one *

You would like Learning Lab to pick up your child at PS 144 (add'l $3 per day)

Your child will be drop off at Learning Lab

Cancellations of Services *

For the safety and welfare of all children attending programs at Learning Lab, we retain the right to terminate services for the following reasons: • The child’s behavior is destructive, uncontrollable, or threatening or violent to other children or staff members. • A parent/guardian refuses to pay tuition.

I Agree