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(918) 559-7323
Our Program
Our Story
Success Stories
FREE Reading Evaluation

Contact Information & Agreement Forms

Contact Information & Agreement Forms

Please fill out the below form to submit your contact information and agree to our terms of service.

Click here to download the 2020 Payments & Rescheduling Guide.

"*" indicates required fields

Step 1 of 4

25%

Contact Information

Parent / Guardian*

First Last

Child's Name*

First Last

Child's Date of Birth*

MM slash DD slash YYYY

Child's Age*

Please enter a number from 0 to 25.

Grade*

Primary Cell*

Secondary Cell

Address*

Street Address City State ZIP Code

Primary Email*

Secondary Caretaker:

This may include any relative or friend who may be picking up the child from their lessons

First Last

Secondary Caretaker Cell*

How did you hear about us?*

Facebook

Radio

Internet Search

Friend

Tulsa Kids Magazine

School

TV

Sign

Other

School Name*

Teacher's Name*

Referring Friend's Name*

What Station?*

What time of day did you hear about us?*

Agreement

By checking this box, I understand and authorize Read Smart® to run credit/debit charge for any payments due and run the credit/debit charge every two weeks for my child’s ongoing reading lessons.*

Yes, I Understand

By checking this box, I understand that if a lesson is canceled for any reason by either the parent/guardian or Read Smart staff, then I will receive a make-up credit which can be used at any time, and can be rescheduled by contacting my teacher via call or text.*

Yes, I Understand

By checking this box, I understand that if the rescheduled lesson is missed, the make-up credit will automatically expire for that session and cannot be rescheduled for a future date/time.*

Yes, I Understand

By checking this box, I understand that if at any time I need to stop lessons with Read Smart® I must notify the company’s administration two weeks prior to the final processed payment. This will allow the teacher to give any final assessments the child may need before leaving the program.*

Yes, I Understand

Signature*

By typing my name in the box below I am acknowledging that I have read the above and agree to the procedures set up by Read Smart®

Today's Date*

MM slash DD slash YYYY

Agreement

Number of Children*

Number of Sessions Per Week*

Number of Sessions Per Week*

Number of Sessions Per Week*

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you will be charged an additional pro-rated amount for the first billing period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you will be charged an additional pro-rated amount for the first billing period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price:

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price:

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total Billed Every 2nd Friday*

Note: If starting in the middle of a two-week billing period, you may be charged an additional pro-rated amount for the first pay period. This total is what your normal charge will be every other Friday.

Price: $47.00

Total

Amount you will be charged on your usual billing cycle every other Friday. If starting in the middle of a billing cycle you may be additionally charged a prorated amount for that time. We will let you know. A $65 one-time supply fee may also be charged.

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