Summer Enrichment Program Registration Form
Limited Space Available
Student Information
Name
First Name
Last Name
Grade Completed
Gender
Please Select
Male
Female
N/A
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Student has an IEP?
Yes
No
Parent(s)/Guardian(s) Information
Please list in order of whom to contact first
*
Emergency Information
Name
First Name
Last Name
Relationship
Phone Number
Format: (000) 000-0000.
Health Information
Family Doctor
First Name
Last Name
Clinic
Phone Number
Format: (000) 000-0000.
Please let us know if this child have any allergies
*
List medications if this child is currently taking
*
Has this child had any serious illnesses or operations?
Yes
No
If yes, please describe
Can this child take part in regular physical activities?
Yes
No
Do you want to indicate any related information?
Summer School Programs
Entering Grades 1-6 (Use this if you want full time all 8 weeks)
Rows
Both Sessions (June - July)
Registration ($75)
Enrichment Program
($600 one time payment in full) OR
Enrichment Program
($80 per week)
Field trips are extra and will be announced in advance.
Entering Grades 1 - 6 (Use this if you only want one month)
Rows
(June or July)
Registration ($75)
Enrichment Program ($85 per week)
Field trips are extra and will be announced in advance.
Entering Grades 7-9
Rows
June - July
Registration ($75)
Enrichment Program ($90 per week)
Field trips are extra and will be announced in advance.
Total
Date of Registration
-
Month
-
Day
Year
Date
Back
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Signature
Please verify that you are human
*
Submit
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