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Classes Fall 2024
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Register Here 2025 - 2026

Student's First name*

Student's Last Name*

Student's Date of Birth*

Month

Day

Year

Student's Grade Level*

Student's Address*

Student's Email Address

Primary Contact Name (First and Last) *

Primary Contact Email*

As primary contact, I am subscribing to Green Room emails.

Primary Contact Phone*

Secondary Contact Name (First and Last)

Secondary Contact Email

Yes, the secondary contact would like to receive Green Room emails.

Secondary Contact Phone

I am interested in registering for: *

Monday - Thursday (4 day program)

Monday/Wednesday (2 day program)

A-La-Carte Class(es)

Tuesdays and Thursdays

Other

Campus Choice*

North Campus

South Campus

Either Campus

Other

Are you interested in direct billing through your charter/correspondence school?*

Yes

Would you like your name and contact info placed on a carpool list for other parents to access?*

Yes

May we use photos of your student for marketing purposes?*

Yes

What is your student's reading level? *

On Grade Level

Below Grade Level

Advanced

Not reading independently yet

Other

Does your student have a device able to be used in the classroom?*

Yes, laptop.

Yes, iPad.

Yes, smart phone.

Other

Does your student have any allergies, learning, or health challenges we should be aware of? If so, please explain. *

Do you agree to hold harmless the instructors at the Green Room and the church campus for accidental injury, illness, or death that may occur while on campus? *

I agree.

I do not agree.

Application Fee

$25

This application fee is required and nonrefundable to complete the registration process.

Questions? Contact Leigh Sloan at 907-315-1338 or thegreenroomlearning@gmail.com

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