Stepping Up Registration : Stepping Up : Programs : What We Do : Club 21 Learning and Resource Center

2023-2024 Stepping Up Registration Form

Parent Name(s)

Child 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 Birthdate

Month

Day

Year

Child School

If child is currently not in school please put "n/a"

School District

Child's Grade for 2023-2024

Club 21 Member?

Yes
No
Unsure

Please list any additional information about your child that will be helpful to the Stepping Up team. (allergies, behaviors, sensory or transition issues, etc.)

Does your child have any additional diagnosis?

When was your child's last hearing and/or vision test?

Stepping Up Payment Options

Classes run from August through May

Payment in Full $540
$100 Deposit (must click box below for recurring payments)
Parent Only ($400-includes materials)
Requesting Regional Center funding OR using Self Determination funds

Monthly Payment Plan Agreement

I paid my payment in full
I will set up a recurring monthly payment by clicking the box below
I will be asking my Regional Center to vendor this program
I will be using Self Determination funds
I will be applying for a scholarship (which is a separate form on the About Stepping Up 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:

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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, charge me today and on the 19th 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

Stepping Up Registration

Stepping Up Registration

2023-2024 Stepping Up Registration Form

Credit Card Information

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