Regent Learning CentreApplication Form

Lower RLC (Nursery - Year 6)

Upper RLC (Year 7 - Year 11)

Sixth Form (Year 12 - Year 13)

Entrance Exam Prep (4+, 5+, 7+ and 11+)

ICT

Harrow

Edgware

SouthallA

B

C

D

E

First name: Surname:

Date of birth: Gender: Male Female

Home address:

Postcode: School year:

Home telephone: Mobile (student):

Email address (student):

Emergency contact name:Emergency contact name:

Emergency contact number:

First name: Surname:

Address (if different from above):

Postcode:

Home telephone: Mobile:

Email address:

First name: Surname:

Address (if different from above):

Postcode:

Home telephone: Mobile:

Email address:

School name:

Any medical conditions:

Any learning difficulties:

Student Details

Father / Guardian Details

Mother / Guardian Details

Student Background Information

Services

Traditional Group Learning

I have read the Fee Schedule and Terms & Conditions, which I acknowledge, form part of the agreement hearby arising.

I permit my child to arrive to/leave the Centre without accompaniment by a parent/guardian.

Maths

At a Centre

English Science Computing Other:

F

For office use only

Harrow: Carmine Court, 202 Imperial Drive, Harrow, Middlesex, HA2 7HG. T: 020 8966 9911. E: harrow@regentlearning.com

Edgware: Boundary House, 2 Turner Road, Edgware, Middlesex, HA8 6BJ. T: 020 8951 6140. E: edgware@regentlearning.com

Southall: 39-47 High Street, Southall, London, UB1 3HF. T: 020 3909 2232. E: southall@regentlearning.com

Please complete the form and return to: The Co-ordinator, Regent Learning Centre, Admission Office.

Signature of Parent / Guardian: Date:

Start Date:

Comments:

Subjects booked for:

W: www.regentlearning.com

Subject Year Slot

How did you hear about us?

Regent Learning Centre website

Referral / word of mouth

Social media

Newspaper / magazine advert

Google search

Online advert

Banner / flyer

Other:

Blended Learning

Private Tuition

Referred by: