Hope Clinic - High School Program Registration

Child Name*

(first & last)

Child Email (optional)

Parent Name*

(first & last)

Parent Email Address*

Parent Phone Number*

Which time is best for your child to attend all 6 sessions of the high school virtual classroom?*

Virtual Classroom 1: Tues/Thurs 1:30pm,-2:15pm Virtual Classroom 2: Tues/Thurs 2:30pm-3:15pm

What grade is your child going into?*

What school does your child attend? (optional)

What questions do you have before you and your student get started?*

What questions do you have before your child gets started? (optional)

Are there any special accommodations that we need to be aware of before teaching your child? (optional)

Are you interested in participating in the parent version of our program (3 session workshop series that equips you to use our curriculum with your child or help your child navigate our online high school program)? *

Yes No Unsure