Summer School Application Form
Student Information
Name
First Name
Last Name
Grade
School Last Attended
Gender
Please Select
Male
Female
N/A
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit 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
*
Have this child had any serious illnesses or operations?
Yes
Type option 2
Type option 3
Type option 4
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 1-3
Rows
Session A (June 1 to 15)
Session B (June 15 to 30)
Summer Sports ($400)
1
2
Primary Italian
($300)
3
4
Art Workshop
($450)
5
6
Tennis & Books
($250)
7
8
Entering Grades 4-6
Rows
Session A (July 1 to 15)
Session B (July 15 to 30)
Multi-Sport
($600)
9
10
Math & Fitness
($550)
11
12
Primary Spanish
($300)
13
14
Tennis & Books
($250)
15
16
Total
Date of Registration
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: