Summer Program Registration Form

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Registration

New Student Returning Student

Student's First Name

Student's Last Name

Email

Student's Date of Birth

Student's Gender

Male Female

Upcoming Grade Level

Select special assistance if needed:

ESL Reading & Math Enhancement Special Ed. / Small Group

(7th-12th Grade, please select 1 math and/or 1 science course you will be taking in FALL 2023)

Algebra 1 Algebra 2 Biology Chemistry Geometry PSAT/SAT Prep

Does your child have any allergies or medical conditions that need attention?

If yes, please explain. If no, enter 'NA':

(1) Parent/Guardian's First Name

(1) Parent/Guardian's Last Name

(1) Parent/Guardian's Driver License Number

(1) Parent/Guardian's Date of Birth

(1) Parent/Guardian's Cellphone

(1) Parent/Guardian's Email

(2) Parent/Guardian's First Name

(2) Parent/Guardian's Last Name

(2) Parent/Guardian's Driver License Number

(2) Parent/Guardian's Date of Birth

(2) Parent/Guardian's Cellphone

(2) Parent/Guardian's Email

Home Address

City

State

ZIP Code

Tutoring Programs