Student Information

Student Name(Required)

Legal First Preferred/Nickname Legal Last

Student Phone(Required)

Student Email(Required)

DOB(Required)

Student Preferred Pronouns(Required)

She/Her

He/Him

They/Them

Other

Enrollment Status(Required)

New Student

Existing Student (Re-Enrollment)

School Level (for 2026/2027)(Required)

Middle School Grade Level(Required)

High School Grade Level(Required)

College Year In School(Required)

School Name(Required)

School District(Required)

School State(Required)

Current Major/Field of Study(Required)

Is your student on, or will they be on, academic probation?(Required)

Yes

Does your student have any siblings currently enrolled in an Untapped Learning program?(Required)

Yes

Please list siblings currently enrolled at Untapped(Required)

Accommodations (6th-12th Grade)(Required)

Accommodations (Post-Secondary)(Required)

Other Accommodations(Required)

Does your student have any of the following diagnoses?

Is there anything else we should know about your student?

Parent/Legal Guardian Information

Parent/Legal Guardian Name(Required)

First Last

Parent/Legal Guardian Phone(Required)

Parent/Legal Guardian Email(Required)

Second Parent/Legal Guardian Name

First Last

Second Parent/Legal Guardian Phone

Second Parent/Legal Guardian Email

Mailing Address(Required)

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

Billing Address

My billing address is different than my mailing address

Billing Contact Name(Required)

First Last

Billing Contact Phone(Required)

Billing Contact Email(Required)

Billing Address(Required)

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

Program Information

Review Pricing & Program Options

Program(Required)

Payment Selection(Required)

Select monthly payments or to pay up-front and in full. Up-front and in-full payments are non-refundable.

Payment Type(Required)

Pay with a credit card or online bank authorization (direct debit). Credit cards incur a 2.9% convenience fee.

How did you hear about us?(Required)

Referral Name or Source(Required)

Program Policies Agreement

Program Policies Agreement(Required)

I confirm that I have read, understood, and agree to all of Untapped Learning’s Program Policies

6th-12th Grade Academic Year Monthly

Enrollment Summary

Academic Year (Monthly): $607.50/month

Total Due Today: $607.50

Next Bill Due:
One month after start date *Credit card payments will incur a 2.9% processing fee.

6th-12th Grade Academic Year Pay in Full

Enrollment Summary

Academic Year (Pay in Full): $6,075 (one time)

Total Due Today: $6075

Next Bill Due:
N/A. Program paid in full. *Credit card payments will incur a 2.9% processing fee. Up-front payments are NON-REFUNDABLE.

Post-Secondary Academic Year Monthly

Enrollment Summary

Academic Year (Monthly): $716.67/month

Total Due Today: $716.67

Next Bill Due:
One month after start date *Credit card payments will incur a 2.9% processing fee.

Post-Secondary Academic Year Pay in Full

Enrollment Summary

Academic Year (Pay in Full): $6,450 (one time)

Total Due Today: $6,450

Next Bill Due:
N/A. Program paid in full. *Credit card payments will incur a 2.9% processing fee. Up-front payments are NON-REFUNDABLE.

6th-12th Grade Continuous

Enrollment Summary

Continuous Coaching: $583.33/month

Total Due Today: $563.33*

Next Bill Due:
One month after start date *Credit card payments will incur a 2.9% processing fee.

Post-Secondary Continuous

Enrollment Summary

Continuous Coaching: $670.00/month

Total Due Today: $650.00*

Next Bill Due:
One month after start date *Credit card payments will incur a 2.9% processing fee.

Once submitted, your payment method on file will be billed according to your plan selections. It may take a few business days for your plan to process. If you have any questions, please reach out to billing@untappedlearning.com.

Once submitted, you will receive a link to add a payment method to your Chargebee account. If you have any questions, please reach out to billing@untappedlearning.com.

John Doe

Student Information

Parent/Legal Guardian Information

Program Information

Program Policies Agreement

6th-12th Grade Academic Year Monthly

Enrollment Summary

6th-12th Grade Academic Year Pay in Full

Enrollment Summary

Post-Secondary Academic Year Monthly

Enrollment Summary

Post-Secondary Academic Year Pay in Full

Enrollment Summary

6th-12th Grade Continuous

Enrollment Summary

Post-Secondary Continuous

Enrollment Summary

Let’s untap your student’s potential together.

Thank you!