Register

REGISTRATION FORM

* Indicates required field

Student Name *

First

Last

Email *

Student Address *

Student Phone *

Parent Phone *

School Presently Attending/Grade *

Option: Reading/English Course # (specify option number below) *

Option: Math/Science Course # (specify option number below) *

Prior ACT Test Dates and Scores *

Any additional information that may be helpful: *

PLease submit registration separately from payment. To pay for the class, you can submit below through PayPal or mail a check. Thanks! *

Submit

When submitting payment through Paypal, please enter the total amount manually. Thanks so much!

Please submit with payment or mail with payment to:

Julie Berhorst
5116 Coventry Waye
Jefferson City, MO 65101

573-690-7065

berhorst@gmail.com

Please pre-register to ensure a spot in the class. Thanks so much!