Child's Name *

First Name

Last Name

1. Parent/Guardian *

First Name

Last Name

Primary Phone Number *

(###)

###

####

Days requesting after school services.

We will do our best to accommodate your request, however request are not guaranteed. A follow up e-mail will be sent to confirm dates.

Monday- Friday

Monday

Tuesday

Wednesday

Thursday

Friday

Please pick one *

I would like Learning Lab to pick my child up from PS 144 ($3 per day pick-up fee applies).

My child will be dropped 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