Raising the Bar Creative Concepts - The Perfect Fit Registration

Please complete the following Registration Form. Your payment will be processed on the next page.

Parent First Name: *

Parent Last Name: *

Email: *

Telephone: *

Cell Phone:

Mailing Address: *

City, State, Zip Code: *

Responsible Party for Payment: *

Student's First Name: *

Student's Last Name: *

Student's Age: *

Student's Gender: *

School: *

Grade Level for 2011-2012: *

Any Known Learning Disabilities:

List 3 Strengths & 3 Weaknesses
of the Learner: *

How did you hear about us?: *

If you answered other above, please specify:

Availability (days and times):
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Monday	Early Afternoon	Early Evening
Tuesday	Early Afternoon	Early Evening
Wednesday	Early Afternoon	Early Evening
Thursday	Early Afternoon	Early Evening
Friday	Early Afternoon	Early Evening
Saturday	Early Afternoon	Early Evening	Anytime
Sunday	Early Afternoon	Early Evening	Anytime

Comments:

Terms and Conditions:

By submitting this enrollment form, the parent or guardian agrees to the financial obligations and policies expressed below.

A one-time processing fee of $225 is due prior to "The Perfect Fit" Consultation. This fee includes 1 - 1.5 hours with our experienced consultant at your home (within 15 miles of the 77098 zip code), a personalized written plan of action tailored to your individual family dynamic, and a thorough follow up visit to explain all facets of the plan described above.

I agree to the terms noted above.

Agree.