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:

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Parent's Phone

School Name or Where you went to school

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?

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)
Requesting 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:

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 27th 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

Meaningful Life Learning Circles

Meaningful Life Learning Circles Registration

Meaningful Life Learning Circles Registration Session 1

Credit Card Information