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

Parent's First Name

Parent's Last Name

E-mail

Address:

City

Zip Code

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.

Child Name

Child's Birthdate

Month

Day

Year

a57lqomu28sr

Child's Grade for 2023-2024 School Year

Please list any additional information that would be helpful to know about your child:

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

Payment Information

$450 payment in full
$100 Deposit
Requesting Regional Center funding OR using Self Determination funding

I made my payment in FULL
I will set up Recurring Payments by checking the box below
I will be asking my Regional Center to vendor this program
I am using Self Determination Funds for this program
I will be applying for a scholarship (which is a separate form on the About CREW page).

If you are requesting funding from your Regional Center, please check 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 funding OR using Self Determination funds

Credit Card Information

Cardholder Name

Credit Card #

Expiration Date

Security Code

Billing Zip Code

Make this a monthly payment?

Yes, bill my card today and on the 2nd 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

The Crew

The Crew Registration

2023-2024 The Crew Registration

Credit Card Information