step-photo-0001.jpg

Summer Tutoring & Enrichment Program

Registration for Freshmen

Student Information
Full Name:
Age:
Street Address:
City:
State:
Zip Code:
Home Phone:
Mobile Phone:
E-Mail Address:
Will the student need school provided transportation from the address listed above:
Shirt Sizes:

Family Information
Parent's/Guardian's Full Name::
Relation to Student:
Street Address:
City:
State:
Zip Code:
Cell Phone:
E-Mail Address:

Emergency Contact
In case of an emergency please contact:
Phone Number:
Relation to Student:
If for any reason I/we cannot be reached, please contact the following person(s) whom I/we hereby authorize to seek emergency medical or surgical care for my/ourchild:
Phone Number:
Relation to Student:

Dietary and Medical Information
Does the student you are registering have any medicial issues we should be aware of:
If yes, please explain:
Does the student have any speical diet needs:
If yes, does the student have a disability that requires a special diet:
If yes, describe the major life activities affected by the disability:
If no, list the medical condition that requires special nutrition or feeding needs.: