Improv & Acting Class

9/18/23-11/6

Student's First Name

Student's Last Name

Birthday

Gender Identity

Grade

We are able to provide some accommodations and supports if needed, such as reading support, noise canceling headphones, etc.

Does your child have a learning challenge (dyslexia, ADHD, etc.)?

Yes

Does your child have an IEP or 504?

Yes

Parent/Guardian's First Name

Parent/Guardian's Last Name

Phone

Referral Source (social media, friend, etc.)

Payment

There is limited space, so a confirmation, an invoice, and further information will be sent to you.

If you have any questions, contact us at (541) 419-3324 or info@samaralearningcenter.org

or pay in-person.

To be added to the roster complete step two.