Meaningful Life Learning Circles Registration : Meaningful Life Learning Circles : Programs : What We Do : Club 21 Learning and Resource Center

Teen/Young Adult's Name:

Birthday

Age

This program is for those 17+ years of age

Gender

Address:

City

Zip Code

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

School Name or Where you went to school

2024-2025 Grade, if still in High School

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?

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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

Payment Options

Payment in Full $200
$100 Deposit (must click box below for recurring payments)
I will be requesting Regional Center funding or using Self Determination funding or applying for a scholarship

If you are requesting funding from Self Determination funds, please check this box:

By checking this box, I understand that if my Self Determination funds are not able to cover the cost of the program, I will be responsible for paying Club 21 in full for the registration fee.

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

Regional Center:

Service Coordinator's Name:

Service Coordinator's Email:

Independent Facilitator name

Independent Facilitator email

Financial Management Service (FMS)

Service Code for Invoice

According to your spending plan

UCI #

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 recurring payment?

No, this is a one-time payment.

Make this a recurring payment?

Your total payment will be .

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

Meaningful Life Learning Circles Registration

2025-2026 Meaningful Life Learning Circles Registration

Credit Card Information

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