Agency Student Registration Form
Day Hab/Service Provider/High School ("Agency") registering a student for SLC classes please read these Guidelines, Choose Selection "Yes" after each paragraph and submit this form. Students attending classes must exhibit appropriate social behavior for a college campus and must be accompanied at all times by the participating Agency.
A registration form must be submitted for each individual student attending the program.
By registering the student named below ("Student") for class ("Class") with Successful Learning Center ("SLC") at any participating SLC location ("Premises") you agree to the following conditions:
Student Contact Information
*Indicates required field
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.
*This information must be updated EVERY semester.
Below please submit the name, address and telephone number of the person/s, agency, or company financially responsible for this student's SLC tuition bill.
It is the Agency's responsibility to get approval for Student to attend class and inform parent/guardian of the tuition cost.
It is the Agency's responsibility to transport or to provide any such transportation for Student to or from Class. The SLC does not accept any other responsibility for Student other than during the time that Student is in attendance of a scheduled Class provided by SLC.
Agency acknowledges and agrees that any Student that Agency places with SLC for education services may not be present on the designated college campus ("Campus") other than during scheduled classes with SLC. If Student is present on Campus other than at such scheduled class time, Agency acknowledges and agrees that SLC shall have no obligation or responsibility for Student, including Student's safety or well-being. As between Agency and SLC, Agency shall be fully liable for Student while on Campus other than when Student is in a classroom during the Student's scheduled classes with SLC.
Agency confirms Student can comprehend appropriate social behavior for a college campus and can interact appropriately with other students, faculty and staff as well as other individuals who they may come in contact with on the Premises.
Agency staff is required to be in class with Student at all times. Agency agrees that students will not be left unattended at any time while on campus.
It is the Agency responsibility to arrive to class on time and inform all staff there is no talking, no cell phone use or texting during class time.
It is the responsibility of Agency staff to follow SLC Agency Guidelines, to be provided to Agency upon registration.
Agency agrees to indemnify, defend and hold harmless SLC, its employees, agents, contractors, directors, officers, shareholders, affiliates, successors and assigns, from any and all claims, losses, actions, damages, costs, liabilities and third party claims, including but not limited to reasonable attorney's fees and disbursements, concerning, relating to or arising out of Student's presence on Campus other than in a classroom during the Student's scheduled classes with SLC.
Agency agrees 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 the Class and/or cancel Student's enrollment in the SLC program thereby terminating this agreement.
Part 2: Class Selection
Thanks for filling out Part 1. You're almost there! A student is listed as registered when we receive your completed Independent Student Guidelines Form (above) and the completed Online Registration Form (below). Please note,
*All dates and classes may be subject to change due to availability.
Payments are due upon registration submission or before December 18th, 2020. Payments received later than the specified due date on the invoice are subject to an initial $25 late fee followed by subsequent late fees up to 15%. Students with an outstanding balance will not be permitted to attend classes until their student account is cleared. Students are subject to withdrawal from the program if payments are not received in a timely manner.
We accept debit/credit card, Pay Pal payments as well as checks and money orders, tuition is due by December 18th, 2020. A $25 Late Fee will be added to all past due invoices. All check and money order payments should be addressed to the Successful Learning Center at PO Box 2116, Monroe, NY 10949.
If you have any questions or problems using this feature please contact Melinda Placanica by phone (845) 662-1322 or email firstname.lastname@example.org
Please Note: All classes will be offered on Zoom ONLY for the Winter semester. There will be no in-person classes for this session.
Tuesday & Wednesday
December 29th - January 20th
Thank you for submitting your registration. You will receive a confirmation email shortly!