Student First Name*						Student Last Name*
Home Phone						Cell Phone
School						Grade Level*
Parent Name(s)*						Parent Email Address*
Home Address*
Home City*				State*				Zip*
Subject area(s), class,or camp you are registering for
Current Grade in Course
List your child’s teachers and their contact information (if applicable).
Does your child have medical conditions we should be aware of? If so, please be sure we have your medical emergency contact information.
Cardholder's Name*
						Billing Address same as Home
Billing Address:*
Billing City*				State*				Zip*
Card Number*				Expiration Date*				Security Code*
I have read and agree with Raleigh Tutoring Policies and Procedures				[View Policies and Procedures]