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329 Way Avenue St.

Louis, Missouri 63122 314 - 258 2955

DUE AUGUST 16, 2013
Parent/Guardian Name ___________________________________________________________________


City ________________________________________ State ____________ Zip _____________________

E-mail Address _________________________________________________________________________
Primary Phone Number ___________________________________________________________________
Childs Name _________________________________________ Date of Birth ______________________

Eligibility for Early Childhood: 2 years old by July 31, 2013

Eligibility for Level 1: 4 years old by July 31, 2013 (see criteria in program description)

I would like to register for:

Early Childhood (EC) (2-4 yrs old)

Level 1 (4-7 yrs old)

Level 3 (8-12 yrs old)*

Graduate Group**

Level 2 (6-9 yrs old)*

*Note age ranges for older levels are suggestions only; we are happy to talk to you about placement for your child if needed
** Note Graduate Group was established for older kids who have gone through Level 3; if you have not gone through the program but are
interested in joining the Graduate Group please contact us directly (contact information below)

Parent sessions and children sessions meet at the same time. While most families bring their child, you have
the option of coming without your child. Please indicate what you would like to do below:

I plan on bringing my child to The Learning Program

I plan on attending The Learning Program without my child (program cost is $175/year)

EC, Level 1, Level 2, Level 3 1
Graduate Group2
Price Break: Enroll in Level 3 and Graduate Group1,2
Attending without child (parent only)


Total Due

1 = Materials included in tuition

2 = Typically, two outings will occur during the year; minimal costs will be required to cover outings

Tuition Payment/Financial Assistance

Tuition will be billed and collected on the first day of class ($50 materials fee plus $300 tuition can be paid in
two payments; one in September and the second in January)
Our philosophy is that finances should not be a barrier for attending; therefore financial assistance is
available as needed
Do you need financial assistance (partial)? Y / N (if yes, a separate form will be sent to you)

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My childs educational setting in September 2013 will be (please check all that apply):

Early Intervention Services



Early Intervention Services receiving (check all that apply): ___ OT ___ Speech ___ PT ___ Other

My school district is _______________________________________________________
Circle one:

Special Education Class

General Education or Blended Class

Private Preschool
Home School

Elementary/Middle School please identify grade attending as of September, 2013 ____________

My school district is _______________________________________________________
Circle one:

Special Education Class

Private School
Home School
General Education or Blended Class
Other, please describe _______________________________________

Other: Are there any medical issues that we need to know about? Y / N
If yes, please explain _________________________________________________________________
Occasionally, food is offered in the classroom. Does your child have any food allergies? Y / N
If yes, please identify _________________________________________________________________
Is your child verbal? Y/N
If no, what form of communication is used (sign, pictures, augmentative assist devices)?
Does your child have any medical equipment supports? Y/N
If yes, what? (please bring to class) _______________________________________________
Are there any behavior or safety issues we need to be aware of? Y/N
If yes, please describe _________________________________________________________
Is there anything else that we need to be aware of? Y/N
If yes, please describe _________________________________________________________

Please Complete and Return by August 16, 2013

Send to The Learning Program of St. Louis, 329 Way Avenue, St. Louis, MO 63122
Or E-mail to
Any questions? Feel free to contact Julie Williams at 314-258-2955

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