Mountain Learning Place

Mentoring/Tutoring Language Arts, Social Studies, Sciences
 Breckenridge, CO. 80424
Director: Kris L. Miller, Ph.d, Licensed, Certified K-12 Educator


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Enrollment Application

The form below is used for internal information only by the Mountain Learning Place staff. Please fill out the enrollment form below and submit when complete. You will then be directed to the payment center where you will have the opportunity to select your session duration (1,2, or 3 day sessions) within the selected schedule period.

* Indicates this is a required field within the form.

Mountain Learning Place Enrollment Form
(Day time sessions only, overnight/camp activities not available)

 
Requested Starting Date: *
Requested End Date: *
First and Last Name of Child: *
Age and Grade in School: *
Day Telephone of Parent: *
Name of Parent/Guardian: *
Contact Email Address: *
City: *
Zip Code: *
State: *
Country: *
Emergency Contact Name: *
Relation to the child: *
Emergency Contact Telephone: *
Please select which schedule week you would like your child to attend. One, two and three day sessions are available within each schedule week.
June 9th through 11th, 2009
  June 16th through 18th, 2009
  June 23rd through 25th, 2009
  July    7th through 10th, 2009
  July   14th through 16th, 209
  July 21st through 23rd, 2009
Please add any information about your child as neccassary:




Content copyright . Kris Miller. All rights reserved.
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