Independent Student Registration Form
Before registering an Independent student with the Successful Learning Center please read these Guidelines, Choose Selection "Yes" after each paragraph and submit this form. Independent Students are determined by the SLC as not affiliated with a Day Hab or accompanied by Day Hab personnel. Independent students must have control over their body and bodily functions. The SLC cannot assist with any aspects of daily living. 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.
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 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 clear.
You are responsible for Student’s travel to and from Class at the designated Premises. SLC shall have no responsibility to transport or to provide any such transportation for Student to or from Class nor does SLC accept any other responsibility for Student other than during the time that Student is in attendance of a scheduled Class provided by SLC.
You confirm that Student comprehends 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.
You confirm Student is capable of controlling their body and bodily functions, unattended, at all times during the Class and while on the Premises. The SLC cannot assist with any aspects of daily living.
SLC reserves the right, in its sole discretion, to require that Student be accompanied at all times, on campus by an Academic Mentor provided by the SLC and paid for by the Student's family. If the SLC determines that such accompaniment is required and you fail to comply, SLC reserves the right to refuse Student’s admission to the Class and/or cancel Student’s enrollment in the program in its entirety.
You acknowledge that Student’s in the Class 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.
SLC and Premises have an arrangement which allows SLC students to enter the Premises (campus, community center, venue) for the sole purposes of attending SLC classes. Entrance to the Premises and use of Premises facilities is a license and not a right and Premises personnel may refuse entrance to any individual at their discretion. SLC has no control over admission to the Premises and shall not be held responsible in the event entrance to the Premises is refused.
You 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 the Class 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.
All mentorship and classroom support must be provided by the Successful Learning Center. Medical Exceptions to this guideline will be evaluated on a case by case basis.
Family, guardians, aides or individual self-hired staff, and/or friends are not permitted to enter the classroom unless prior permission has been granted by a director of the SLC.
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!