Home SE Registration Form

SE Registration Form

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Summer Enrichment Program

Student Information

Student Name

First

Last

Special Needs/Allergies/Medical/Other

Date of Birth

Last Grade Completed:

T-Shirt Size:

Parent/Guardian Information

Parent/Guardian Name

First

Last

Email

Address

Address Line 1

City

State

Zip Code

Work/Cell

Home Phone:

Please check which program child will participate:

Enrichment Program (5/28-7/19) 10:00AM-2PM @ $90/week/child
Full SE Program (5/28-7/19) 6:30AM-6PM @ $100/week/child

Registration Fee: $50.00 Non-Refundable:

Payment Type:

Mail Check to GWBBC
Bill Pay thru my Bank
Pay in person

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