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Student Registration Form

Before registering with the Successful Learning Center please update the following information and submit the Registration form. By registering, individual named below ("Student") for class ("Class") with Successful Learning Center ("SLC") at any participating SLC location ("Premises") you agree to the following:

Has the student taken classes at the SLC before?
Permission to use photo

Student's Physical Information

The following is a request for information which will insure that each individual students' needs are met. Please indicate the status of any condition/s which will help us provide a successful experience. All information will be kept confidential.

Are there any exhibited behavior issues?
Are there any fears or triggers we should know about?


If Student is a minor (under legal age of consent) or is otherwise unable to legally consent to these Guidelines, for any reason whatsoever, you warrant that as the undersigned parent or guardian you have legal guardianship of Student and the capacity to bind yourself and Student to the terms of these Guidelines on Student's behalf.
​​The undersigned parent or guardian is responsible for the payment of the invoice generated by the SLC​ based on the submission of this registration form. Payments received later than the specified due date on the invoice are subject to an initial $25 late fee. Students with an outstanding balance will not be permitted to attend classes until their student account is clear.

I acknowledge that Student’s attending any SLC class/club/event may involve certain risks (some of which may not be fully appreciated at the time of signing) and that injuries, death, property damage or other harm could occur to Student or others.  You accept and voluntarily incur all risks, waive and forever discharge all claims whether known and unknown, and agree to release, hold harmless, defend and indemnify SLC and the Premises, including their respective officers, directors, employees contractors, shareholders, agents, affiliates or insurers (“Released Parties”) for any injuries, damages, or harm which arise during or result from Student’s participation in the Class, regardless of whether or not caused in whole or in part by the negligence or other fault of the Released Parties.

I acknowledge and agree that in the event of a breach or any of your obligations under these Guidelines, SLC in its sole discretion, may refuse Student's admission to class/club/event and/or cancel Student's enrollment in the SLC program thereby terminating this agreement.  ​The SLC reserves the right, at its discretion, to refuse or withdraw a student from the program at any time, for any reason. You may not assign any of your or Student's rights or obligations hereunder, whether voluntarily or involuntarily without the SLC's written consent.

Parent or guardian acknowledges

June 2023

Pleasantville-Manville Road
Discussions in the Gallery - 11 First Street, Warwick

July 2023

Pleasantville-Manville Road
Discussions in the Gallery - 11 First Street, Warwick
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