Summer Tutoring Enrichment Program (9th Grade)

Summer Tutoring & Enrichment Program

Full Name:

Student Information

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.:
Vegetarian, Food Allergy, Other

2011 Bienville Street
New Orleans, LA 70112

Phone: (504) 324 - 7061
Fax: (504) 459 - 2602