REGISTRATION FORM

Windsward Application

Date Date / MM / DD YYYY
Parent's First Name
Parent's Last Name
Student's Last Name
Student's First Name
Gender
Date of Birth Date of Birth / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Mobile Phone Mobile Phone - ### - ### ####
Email
HOW DID YOU HEAR ABOUT US?
Referral Google Yahoo Social Media
ACADEMIC AND TUTORING INFORMATION
School
School name
Student's Grade
Principal
Student’s favorite subject/s in school:
Subjects needed to work on:
Is there anything else we should know about your child?
Would you like to give Windsward authorization to speak to teachers and or school staff regarding any academic and social needs of your child?

Would you like to give Windsward authorization to speak to teachers and or school staff regarding any academic and social needs of your child? Yes No

If yes, please list their names along with their contact information.
Teacher’s Name:
Subject:
Telephone Number: Telephone Number: - ### - ### ####
Email
Authorization
Name
Date Date / MM / DD YYYY
Any images of students will be used for educational purposes in the program at Learning Levels.
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Full Name

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