Club Connections Registration : Club Connections : Programs : What We Do : Club 21 Learning and Resource Center

Teen/Young Adult's Name:

rozichauwm2o

Age

Gender

Address:

City

Zip Code

Birthday

Would you like to be contacted in addition to your parents?

If yes, please provide your email and phone number below

Teen's/Young Adult's Email

Teen's/Young Adult's Phone Number:

Parent's Name

Parent's E-mail:

Parent's Phone

DO YOU GIVE PERMISSION FOR CLUB 21 TO SHARE YOUR NAME, EMAIL, AND PHONE NUMBER WITH THE PROGRAM ROOM PARENT?

Room parents will be coordinating opportunities for connection outside of class meetings.

Have you participated in Club Connections before?

School Name or Where you went to school

2024-2025 Grade, if still in High School

Allergies to Food (If none, type "N/A")

Allergies to Meds (if none, type "N/A")

Current Meds (and dosage)

Special Diet:

None
Gluten Free
Dairy Free
Vegetarian
Other:

If "other" please indicate what that is:

Answering the questions below, will help our Club Connections Team create lessons that can meet a diverse group of needs.

Any difficulty with sight or hearing?

If yes, please indicate what those are:

Does your child have any behavioral triggers or are there any situations that would require further assistant/intervention?

What is your teen's/young adult's main method of communication

Please explain your child's reading comprehension and written expression

Does Club 21 have permission to release photos of your teen:

by clicking "yes" you give your consent

Club Connections Payment Options

Payment in Full $540
$100 Deposit (must click box below for recurring payments)
Requesting Regional Center/Self Determination funding or applying for a scholarship

If you are requesting funding from your Regional Center, please check this box:

By checking this box, I understand that if my Regional Center does not approve my registration I will be responsible for paying Club 21 in full for the registration fee.

Regional Center

Regional Center Coordinator Name

Regional Center Coordinator Email

Additional Comments or Questions

If you are using Self Determination funds, please fill out this information:

Independent Facilitator name

Independent Facilitator email

Financial Management Service (FMS)

Service Code for Invoice

According to your spending plan

FMS email

Payment Option

I will be paying for the program
I will be requesting Regional Center/Self Determination funding or applying for a scholarship (which is a separate form on the About Club Connections page).

Credit Card Information

Cardholder Name

Credit Card #

Expiration Date

Security Code

Billing Zip Code

Make this a monthly payment?

Yes, charge me today and on the 12th of every following month.

Make this a monthly payment?

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

Club Connections Registration

2024-2025 Club Connections Registration

Credit Card Information

Follow Us