Study Hall

Your Information

LRBC Virtual Study Hall Registration Form Thursdays, 4:30p.m. – 6p.m. Grades: 1– 8

Student Name*

First Last

Date of Birth*

Gender*

Current School Grade

Student's Age*

Student Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

School Name*

School Address*

How Student currently attends school*

Parent Name*

Prefix First Last

Home Phone*

Cell Phone*

Work Phone

Email*

Please answer below to indicate permission for student to attend LRBC Study Hall:*