Elsass Summer Application

Elsass Academy Summer Application
Parent 1 Full Name *
Parent 2 Full Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent 1 Number *

Area Code Phone Number
Parent 2 Number

Area Code Phone Number
Parent 1 Email *
example@example.com
Parent 2 Email
example@example.com
First Child Information
Last Name *
First Name *
Sex *
Birth Date *

Month Day Year
Grade (Going In To) *
Current Age *
Summer Program *

Term 1: June 6 - July 8 (5 weeks) for $1295 Term 2: July 11 - Aug 12 (5 weeks) for $1295 All Summer Option for $2400
All Summer option is broken into 3 payments

Payment Dates: 6/1, 7/5, and 8/1
Special Information Concerning Child:
Second Child Information
Do you have a second child?

No Yes
Last Name
First Name
Sex
Birth Date

Month Day Year
Grade (Going In To)
Current Age
Summer Program

Term 1: June 6 - July 8 (5 weeks) for $1295 Term 2: July 11 - Aug 12 (5 weeks) for $1295 All Summer Option for $2400
All Summer option is broken into 3 payments

Payment Dates: 6/1, 7/5, and 8/1
Special Information Concerning Child:
Signature

Clear
Should be Empty:

Elsass Academy Summer Application