Skool-Aid Summer Program Registration Form
Registration Form I.D.#___
Student Name (Last, First):______________________
Date of Birth (Month/Date/Year):___ /____/____ Gender: Male___ Female___
Parent/Guardian Name (Last, First):________________________ Relationship to the student:_____________________
Daytime phone No.:______________________
Home Address: _____________________________________________________
Home Phone No.: ___________________ School Name: _______________________________
Current Class: Regular___ Advanced___ Special Education___ ELD___
Current Grade: PreK K 1 2 3 4 5 6 7 8 9 10 11 12 adult
What is the student's primary language spoken at home? _________________________________________________
What is the parent's primary language spoken at home? _________________________________________________
Does the student have any special needs? Yes _____ No_____
If yes, please explain below._________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Does the student have any special medical condition(s)? Yes No If yes, please explain below.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Please provide names and telephone numbers for an emergency
First Contact Person: Name (Last, First): _____________________________________________________________
First phone No.: ____________________________________ Second phone No.:____________________________
Cellular phone No.: _________________________________ Relationship to the student: _____________________
Second Contact Person: Name (Last, First): _______________________________________
First Phone No._____________________________________ Second phone No.: ____________________________
Cellular phone No.:__________________________________ Relationship to the student: ______________________
MEDICAL AUTHORIZATION:
In the event of illness or injury, I hereby consent to whatever X-ray, examination, anesthetic, medical, dental or surgical
diagnosis or treatment and hospital care from a licensed physician and/or surgeon as deemed necessary for the safety
and welfare of my child. It is understood that the resulting expenses will be the responsibility of the parent(s) or guardian(s)
or participant.
Parent name:________________________ Signature:_____________________________ Date: ____/_____/______
Medical insurance provider:____________________ Group No.:_________________ Policy/ID No.:_______________
Doctor's Name (Last, First):_______________________________ Phone No.:_(____)_________________________
Dental insurance provider:_____________________Group No.:___________________Policy/ID No.:______________
Dentist's Name (Last, First):_______________________________ Phone No.:_(____)_________________________
WAIVERS
I, the undersigned, hereby release and discharge the SKOOL-AID Learning center, teachers, and employees from all
liability arising out of or in connection with my child's attendance at this facility. For the purpose of this agreement, liability
means all claims, demands, losses, causes or action, suits, or judgments of any and every kind that I, my heirs, executors,
administrators, or assignees may have against the SKOOL-AID because of any death, personal injury or illness, or
because of any loss or damage to property, that occurs during the attendance at SKOOL-AID.
_____________________________________________________________ Date: _____/______/___________
Signature of parent/guardian& date
CLASS FEES (due 1st of each month, in advance)
$40/hour (k-8) $45/hour (9-12) per student
$495/mo.(pre-k) $25/hr.(adult ELD)
$65 registration fee Add $20/hr. for 1-1
$45 diagnostic test fee (waived if registered)
5% discount for 3 months advance payment
Start Date:_____/_____/________
I have read and agree to the fee described above. I understand that a $25.00 return check charge will be applied to each
returned check. Students shall not miss a class without a minimum 24-hour advance notice. Make-up class schedule
should be made within 3 days from the original class date.
_______________________________________________________ Date:______/______/______ Initial____
Signature
Summer program sessions and tuition fees
Session 1: June 20, 2011 ~ July 15, 2011 (no class on July 4)
Session 2: July 18, 2011 ~ August 12, 2011
Morning session (Mon.-Fri.) 09:00 a.m.-12:00 p.m.-------- session 1($695)session 2($695)
Afternoon session (Mon.-Fri.) 01:00 p.m.-04:00 p.m.-------- session 1($695)session 2($695)
Full day session (Mon.-Fri.) 09:00 a.m.-04:00 p.m.---------session 1-$1,300/session 2-$1,300 (Bring your own lunch!)
Tuiton Fee is $1,200 (morning or afternoon session) for students taking both sessions(session 1 & 2)/$20 material fee per
session to be added when registered
Registration Form I.D.#___
Student Name (Last, First):______________________
Date of Birth (Month/Date/Year):___ /____/____ Gender: Male___ Female___
Parent/Guardian Name (Last, First):________________________ Relationship to the student:_____________________
Daytime phone No.:______________________
Home Address: _____________________________________________________
Home Phone No.: ___________________ School Name: _______________________________
Current Class: Regular___ Advanced___ Special Education___ ELD___
Current Grade: PreK K 1 2 3 4 5 6 7 8 9 10 11 12 adult
What is the student's primary language spoken at home? _________________________________________________
What is the parent's primary language spoken at home? _________________________________________________
Does the student have any special needs? Yes _____ No_____
If yes, please explain below._________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Does the student have any special medical condition(s)? Yes No If yes, please explain below.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Please provide names and telephone numbers for an emergency
First Contact Person: Name (Last, First): _____________________________________________________________
First phone No.: ____________________________________ Second phone No.:____________________________
Cellular phone No.: _________________________________ Relationship to the student: _____________________
Second Contact Person: Name (Last, First): _______________________________________
First Phone No._____________________________________ Second phone No.: ____________________________
Cellular phone No.:__________________________________ Relationship to the student: ______________________
MEDICAL AUTHORIZATION:
In the event of illness or injury, I hereby consent to whatever X-ray, examination, anesthetic, medical, dental or surgical
diagnosis or treatment and hospital care from a licensed physician and/or surgeon as deemed necessary for the safety
and welfare of my child. It is understood that the resulting expenses will be the responsibility of the parent(s) or guardian(s)
or participant.
Parent name:________________________ Signature:_____________________________ Date: ____/_____/______
Medical insurance provider:____________________ Group No.:_________________ Policy/ID No.:_______________
Doctor's Name (Last, First):_______________________________ Phone No.:_(____)_________________________
Dental insurance provider:_____________________Group No.:___________________Policy/ID No.:______________
Dentist's Name (Last, First):_______________________________ Phone No.:_(____)_________________________
WAIVERS
I, the undersigned, hereby release and discharge the SKOOL-AID Learning center, teachers, and employees from all
liability arising out of or in connection with my child's attendance at this facility. For the purpose of this agreement, liability
means all claims, demands, losses, causes or action, suits, or judgments of any and every kind that I, my heirs, executors,
administrators, or assignees may have against the SKOOL-AID because of any death, personal injury or illness, or
because of any loss or damage to property, that occurs during the attendance at SKOOL-AID.
_____________________________________________________________ Date: _____/______/___________
Signature of parent/guardian& date
CLASS FEES (due 1st of each month, in advance)
$40/hour (k-8) $45/hour (9-12) per student
$495/mo.(pre-k) $25/hr.(adult ELD)
$65 registration fee Add $20/hr. for 1-1
$45 diagnostic test fee (waived if registered)
5% discount for 3 months advance payment
Start Date:_____/_____/________
I have read and agree to the fee described above. I understand that a $25.00 return check charge will be applied to each
returned check. Students shall not miss a class without a minimum 24-hour advance notice. Make-up class schedule
should be made within 3 days from the original class date.
_______________________________________________________ Date:______/______/______ Initial____
Signature
Summer program sessions and tuition fees
Session 1: June 20, 2011 ~ July 15, 2011 (no class on July 4)
Session 2: July 18, 2011 ~ August 12, 2011
Morning session (Mon.-Fri.) 09:00 a.m.-12:00 p.m.-------- session 1($695)session 2($695)
Afternoon session (Mon.-Fri.) 01:00 p.m.-04:00 p.m.-------- session 1($695)session 2($695)
Full day session (Mon.-Fri.) 09:00 a.m.-04:00 p.m.---------session 1-$1,300/session 2-$1,300 (Bring your own lunch!)
Tuiton Fee is $1,200 (morning or afternoon session) for students taking both sessions(session 1 & 2)/$20 material fee per
session to be added when registered
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| Summer Program Registration Form |