Summer LAF - High School Registration

---------------------------- High School Registration Form ----------------------------

Student First Name	*
Student Last Name	*
Date of Birth	*
Social Security Number	*
Address1	*
Address2
City	*
State	*
Zip	*
Telephone	*
Cell Phone
Email	*
Parent/Guardian Name	*
Emergency Contact	*
Emer. Contact Telephone	*
Grade in Fall 2008	*
Name of Current School
Special Health Conditions (if any, please explain)
Dietary Restrictions (if any, please explain)

High School Course Selection	*	English 10 (HS-E2) English 11 (HS-E3) Pre-calculus (HS-M4)
Would you like school provided lunch?	*	Yes No
Would you like school provided transportation?	*	Yes No

Payment Type		Check MasterCard Visa
Credit Card Number
Exp. Date

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