Registration Form

Welcome to Alpha Reading Center Registration! 
Please fill out the following form.
FAMILY INFORMATION
STUDENT EMERGENCY CONTACT & PICK-UP AUTHORIZATION
If "No" name the person(s) authorized for picking up your child. (They must provide proper ID)
PAYMENT INFO, TERMS & CONDITIONS
Credit Card Details
By submitting your credit card you consent the initiation of payments on your behalf that we provide to you and/or for services that you requested ahead of time.

Assumption of Risk: “As a participant or parent/guardian of a participant in this program, I understand that the students are consistently well supervised and are engaged in various activities pertaining to the program. I also recognize and acknowledge that there are certain risks of physical injury and I voluntarily agree to assume the full risk of any injuries, including death, damages or loss, regardless of severity, that my minor child/ward or I may sustain as a result of participating in any and all activities connected with or associated with this program held on or off Alpha Reading Center's property.”

“I further agree to waive and relinquish any and all claims I or my child/ward may have as a result of participating in this program (held on or off Alpha Reading Center property) against Alpha Reading Center, including its independent contractors, officials, agents, volunteers, and employees.”

“I do hereby fully release and forever discharge Alpha Reading Center and its independent contractors, officials, agents, volunteers, and employees from any and all claims from injuries, including death, damages, or losses sustained by me or my minor child/ward and arising out of, connected with, or in any way associated with the activities of this program held on or off Alpha Reading Center property.”

Release of Liability: I understand that I elect for my child to receive academic services provided by Alpha Reading Center and give permission for my child to participate in activities in relation to those academic services. I understand that by signing this agreement I am also giving permission to allow photographs or video taken of my child for promotional, teaching, or training purposes. I understand that it is my responsibility to arrange for transportation at the end of each class.

Medical Emergencies: This emergency release treatment form enables the parent/guardian to authorize the provision of emergency treatment for children who become ill or injured while under Alpha Reading Center’s authority, when parents or guardians cannot be reached.

In the event that I cannot be reached by phone, I hereby give my consent for the administration of any medical treatment deemed necessary for my child by a licensed medical professional.

This form is completed and signed with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.

I have read and fully understand the above Waiver & Release of all Claims & Assumption of Risk.

Payment Policies: Payments must be paid on time. Please keep track of your payments and keep your account current. Electronic checks must be made payable to Alpha Reading Center. All major credit cards are accepted. It is your responsibility to keep your credit card information on file current. Late fees and processing fees will apply for any late payments including those incurred by 'on file' information that is not current.

A late fee will be charged to a required credit card on file for past due balances in the following increments:

1-30 days: $10 late fee
31-60 days: $25 late fee
61-90 days: $50 late fee
Over 90 days: $75 late fee plus student will be dropped from enrollment and will be assessed a 10% monthly finance charge until balance is paid in full.

Parents/Guardians are responsible for any attorney fees, court costs and/or collection for the recovery of delinquent payments.

STUDENT INFORMATION
Add Fields for Additional Student