Dickens Sanomi Academy Summer School Registration

Dickens Sanomi Academy Summer School Registration
Student's Name
Grade Level
Parent/Guardian Information
Parent/Guardian Full Name

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Emergency Contact Information
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pick-Up Persons
Pick-Up Person 1 Name
Pick-Up Person 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pick-Up Person 2 Name
Pick-Up Person 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Summer School Program

This 5-week program is to help students who are struggling academically in Reading and Math. The goal is to help build Reading and Math foundational skills.

June 15th to July17th

8am to 12pm

$60 per week | First payment due: June 12th

All weekly payments are due the Friday before - CASH ONLY.
Payment Preference
Families are responsible for all registered weeks unless a cancellation request is submitted via email (nbrooks@dickenssanomiacademy.org)
Parent Signature
Consent and Waiver
Parent/Guardian Name (Consent)

First NameLast Name
Parent/Guardian Signature (Consent)
Date

MonthDayYear
Date
Medical and Physical Limitations
Should be Empty:

Parent/Guardian Information