Summer Intensive Registration Form

Student's Name *
Student's Name
Student's Birthdate *
Student's Birthdate
Student's Cell
Student's Cell
Student's Home
Student's Home
Student's Address *
Student's Address
Mother's Name *
Mother's Name
Mother's Cell *
Mother's Cell
Mother's Home
Mother's Home
Mother's Work
Mother's Work
Mother's Address
Mother's Address
Only required if different from student's address.
Father's Name *
Father's Name
Father's Cell *
Father's Cell
Father's Home
Father's Home
Father's Work
Father's Work
Father's Address
Father's Address
Only required if different from student's address.
Backup Emergency Contact *
Backup Emergency Contact
This is the person we will try to contact if we are unable to reach either of the parents/guardians.
Emergency Contact's Cell *
Emergency Contact's Cell
Emergency Contact's Home
Emergency Contact's Home
Emergency Contact's Work
Emergency Contact's Work
Emergency Contact's Address
Emergency Contact's Address
Please list anything we should know (health problems, medicines, allergies, disabilities, etc)
Subject to Director Approval
Weeks *
Please identify which weeks you intend to attend