Child's Name *

First Name

Last Name

1. Parent/Guardian *

First Name

Last Name

Primary Phone Number *

(###)

###

####

Continue with same day/s as the first semester. *

Yes

No

Not continuing

Days requesting after school services.

Only complete if you answer NO to the question above. We will do our best to accommodate changes, however changes are not guaranteed. A follow up e-mail will be sent to confirm.

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