Name *

First Name

Last Name

Phone *

(###)

###

####

Child's Name *

First Name

Last Name

Which sessions are you interested in? *

If you are interested in group sessions, please have a separate form filled out for each child who wishes to participate.

One-hour 1:1 sessions @ $50 per session, per learner

Two-hour group sessions @ $100 per session, per learner

If seeking 1:1 sessions, are you interested in following the intended series structure, or would you prefer more personalized sessions for your child?

I wish to follow the intended series structure.

I would like to personalize these sessions for my child.

I'm not sure yet and would love to discuss this with you more.

Do you intend to pay with Blue Ridge charter school funds? *

Yes

No