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Colearn Club Learner Intake Form
We are so excited to have you join the Colearn Family! To help us get your learner set up into our systems, please complete this form at your earliest convenience.
First name
*
Last name
*
Grade
*
Please Select
K
1
2
3
4
5
6
7
8
9
10
11
12
Student's Gender
*
Male
Female
Student DOB:
*
Month
/
Day
/
Year
Home Address:
*
State/Region
*
City
*
Student Ethnicity
*
White
African American
Hispanic
Asian
Other
Prefer not to answer
Parent Email
*
Phone number
Does your student have any special needs or learning challenges that you feel we should be aware of?
*
Changes to Services Policy Acknowledgment:
Subscription to educational services through Colearn Academy
DBA
Colearn Club Inc. are charged on a monthly basis and will auto deduct on the same day of the month services were originally initiated. Any changes to elected services or discontinuation of subscribed services requires a 30 day notice and a final billing cycle to date of notice.
Acknowledgement of Terms-
type the full name of responsible adult below to acknowledge agreement of terms above.
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