Student Registration Form 2018-2019


    If Parent/Guardian can’t be reached, in emergency please call and, if necessary, release my child to:

    * If no contact can be made, and in the event of an emergency, you authorize necessary medical care from/at an emergency hospital. Students who are ill or become ill may not attend the programs until healthy again.

    *Medical Conditions or Allergies (required):

    * In order to maintain the academic integrity of our enrichment environment, students with disruptive behavior will be given one warning, which will include notice to parents. If any disruptive behavior continues, parents will be asked to permanently remove the students(s) from the class without refund. Heart for Education™ reserves the right to refuse service to anyone. By signing this registration form you agree to all requirements and authorize Heart for Education™ to speak with your child’s teacher(s).

    *Pick one of the following options:

    *Pick-up Contact Name:

    Please choose the programs that apply:

    Only 9 monthly payments. No hidden fees.

    *First, choose your form of payment:

    *Next, check the programs you would like to register for:

    Kinder Catchers

    • 100 $
    • 450 $
    • 900 $

    Homework Helpers and Simply Spanish

    • 320 $
    • 1440 $
    • 2880 $

    *Next, check the programs you would like to register for:

    Kinder Catchers

    Homework Helpers and Simply Spanish

    There is an annual, non-refundable registration fee of one month’s service which counts as one month’s payment. No additional payment due in December.

    For Payment in Person:

    Full amount must be paid before registration is validated.  Final totals due ARE NOT reflected at the bottom of this registration form for non-online payments but will be listed on submission confirmation.  Customer must make check or money order payable to Heart  for  Education ™ LLC. $35 fee for all returned checks.

    For Online Payments:

    There is a 2.9% processing fee applied to all online payments. This processing fee is automatically applied to the final total before online checkout. This fee is not applied to any customers paying in person or through check/money order.

    Liability Statement:

    I voluntarily agree to participate and/or have my child participate in this program, including special events. I realize that every precaution is taken to eliminate any injuries or hazards and that a competent supervisor, manager, or learning assistant is present; however, in the event of any injury to myself or to my child, I hereby waive, release and hold harmless the supervisor, manager, learning assistant, Heart for Education™ and its employees. I acknowledge that there is a $10 fee for every 15 minutes or portion thereof for students  who are not picked up by the scheduled time. I also acknowledge that all invoices must be paid by the 10th day of each month  or a 10% late fee will be added. Furthermore, by signing below I agree that my or my child’s image, likeness, or statements may be used in Heart for Education publications.
    *Parent/Legal Guardian Signature (Required):


    Call Heart for Education™ at (626) 622-0336 or (626) 622-1067 or email