Excell Program Fall 2022 Student Application & Agreement

Student Application & Agreement

LACBPE Excell Program Fall 2022
To complete this application please provide, at minimum, the required information on this form (indicated by a red asterisk, "*" ), and your signature, which indicates you have read and accepted the following documents:
(A) The Excell Program's Policies and Procedures (Excell rules); and
(B) The Release of All Claims for Excell Participation.

Please Note: if you have more than one student that you are registering, you must submit a separate application for each student.
Student Information
Student Name *

First Name Last Name
Email Address
Ex: jane.doe@myemaildomain.com
Gender *

Male Female
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State

Postal / Zip Code
School Information
School Name
Grade Level

2 3 4 5 6 7 8 9 10 11 12
Math Class

2nd Grade Math 3rd Grade Math 4th Grade Math 5th Grade Math 6th Grade Math 7th Grade Math/Pre-Algebra Algebra 1 Geometry Algebra 2 Trigonometry/Pre-Calculus Calculus
Science Class

2nd Grade Science 3rd Grade Science 4th Grade Science 5th Grade Science 6th Grade Science General Physical Science Biology/Life Science Chemistry Physics
SAT Class - This is generally for grades 10 and up. *

Yes No
Please note if you choose "Yes" your student will forego the science class for the SAT Prep Class.
Parent / Guardian / Emergency Contact Questions
1st Person *

First Name Last Name
1st Person's Relationship to student *
Parent or Guardian
1st Person Cell Number *
1st Person Email *
example@example.com
1st Person Home Number
1st Person Work Number
2nd Person Name

First Name Last Name
2nd Person's Relationship to student
Parent or Guardian
2nd Person Cell Number
2nd Person Email
example@example.com
2nd Person Home Number
2nd Person Work Number
Emergency Contact Name *

First Name Last Name
EC's Relationship to student *
EC's Phone Number *
Phone device type

Cell Phone Landline
Please list significant medical problems this student may have: *
Enter "None" if no medical problems
Program Participation Information
How did you learn about Excell?
Will you be enrolling siblings in the program?

Yes No
How many siblings will you enroll? *
Program Cost
The program cost $85 for the first student and $65 for each additional sibling. Payment is due the first day of the session. Once you complete this form, you will receive a confirmation email. Click here to view and download the session schedule.
How much will you pay for this student? *

$85 $65
1st Student *

First Name Last Name
I, {1stPerson28}, hereby acknowledge that I have read the Excell Program Policies and Procedures for Virtual Sessions and agree to the Release Claims for Excell Program Virtual Participation. I also confirm that the aforementioned documents have been made available for me to view online and for me to print copies for my records.
Signature *

Clear
Signature Date *

Month Day Year
Date
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Student Application & Agreement

Student Information

School Information

Parent / Guardian / Emergency Contact Questions

Program Participation Information

Program Cost