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Empowered Learning Interest Form

Please use this form if you are interested in the Empowered Learning program.

Submitting this form is not approval to begin care; please speak with an enrollment staff person.

Allow at least two business days for a response, but feel free to call us at 626-967-9337.

Student name*

Answer required for "Student name"

Date of birth (MM/DD/YYYY)*

Answer required for "Date of birth (MM/DD/YYYY)"

Grade level*

Answer required for "Grade level"

Home zip code

Answer required for "Home zip code"

School child is attending*

Answer required for "School child is attending"

Parent name*

Answer required for "Parent name"

Answer required for "Email"

Daytime phone number*

Answer required for "Daytime phone number"

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"