Middle School Writing Survey Course Registration Form
Student’s Name and grade level: __________________________
Parent/Guardian’s Name: ___________________
Home Address: ___________________________
___________________________
___________________________
Daytime Phone: _____________________ Evening Phone: ____________________
Email address: ____________________________
Course Dates, Location and Time:
Mondays, 10 to 11 AM, 9/10/2012 through 5/20/2012
8215 Burning Forest Ct., Springfield, VA
Tuition: $450.00 per year, $50 per month for 9 months. First month's tuition (September
2012) due upon enrollment.
Withdrawals:
Students will gain the most benefit from enrolling for the full year. However, course
drops may occur following the last class of the most recent pre-paid month. No refunds
will be issued if a course drop occurs at another time. Parents are encouraged to contact
The Writing Well at any time to discuss their child’s progress or other special
circumstances.
Session Make-ups:
Private make-up sessions are one half hour in length and available at no extra charge.
Please sign and date below. Your signature confirms your agreement to the terms of the
contract. To reserve your student’s place in the course, please mail this form with the
first month’s payment to the address below.
Signature: _________________________________ Date: _____________________
703-909-7425 8215 Burning Forest Ct., Springfield VA, 22153
http://www.thewritingwellonline.com thewritingwell@earthlink.net 703-909-7425