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Please complete our online Application Form below. If you prefer, you may download the Application Form.


APPLICATION FORM

Application
Please purchase a membership or package before using this page. If you have already done so, you may enter the code that was sent to you in your order confirmation email.
If you do not have a registration code, please purchase a plan by clicking on "Add to cart" in one of the options below:

Student Information

Student's First Name
Student's Last Name
Current school/last school attended/not attending
If in college, write year of college (i.e. freshman, sophomore, junior, senior) or year in graduate school or write "graduated" if no longer in school
City
State/Province
Zip/Postal

Parent / Guardian 1 Information

Parent / Guardian 2 Information

Alternate Emergency Contact

Scheduling Preferences

Learning Assessment

(specify subject, topics, concepts, or content area)

Learning Style

Signature

I, parent or guardian of the above-named child, give my approval for my child to participate in any and all activities of Blended Learning and Study Center. I further hereby release, indemnify, and hold harmless the organizers, instructors, and staff of Blended Learning and Study Center. I likewise waive, to the extent not covered by liability insurance, any claim against any person overseeing my child’s activities and transporting my child to and from activities. If I choose the study abroad package for myself or the above named child, I agree to pay the full amount before beginning with the study abroad process or thereby canceling any further activities with Blended Learning and Study Center until the full amount is paid. I also agree to make all payments required by the chosen plan and activities associated with my registration or the registration of the above-named child.

Photo Release

I give Blended Learning and Study Center the right to take photographs of me, my family, or my child in connection with learning experiences at the facility and on outings to field trips and other activities. I authorize Blended Learning and Study Center, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Blended Learning and Study Center may use such photographs of me without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

FERPA NOTICE

The Family Educational Rights and Privacy Act of 1974 (FERPA) governs the release of records maintained by institutions of education and access to student records, including requests for information from parents, guardians, spouses or others designated by the student/parent. Generally, without a parent’s/students written consent Blended Learning and Study Center may not disclose information from a student’s tutoring records. Parents who want to allow information released to individuals about their student progress whether over the phone, in person, or electronically must complete this declaration form providing a standing release indicating who may receive this information.

I give Blended Learning and Study Center permission to release information regarding my child’s tutoring progress to myself and any individual listed below:

OTHER DOCUMENTATION AND ITEMS REQUIRED

Please upload the following documents in PDF format. If you do not have these documents in this format, please mail them to: Blended Learning & Study Center, P.O. Box 110701, Trumbull, CT 06611.
Drop a file here or click to upload Choose File
Maximum upload size: 2.1MB
Drop a file here or click to upload Choose File
Maximum upload size: 2.1MB
Drop a file here or click to upload Choose File
Maximum upload size: 2.1MB
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