Summer School Application Step 1 of 3 33% Summer School: June 22-July 31, 2015 Summer School is a 6- week program designed for incoming Kindergarteners to 8th graders. The program focuses on readiness skills for incoming Kinders, grade level review for 1st to 5th, and study and organizational skills for 6th – 8th. All classes will begin daily at 8:30am until 11:30am. Complete all sections, writing “N/A” if something does not apply. Regular tuition for the 6-week Summer School is $700. Register by 3/30/2015 to receive $100 discount on tuition. $50 late fee will apply for registrations after 6/5/2015. The application must accompany a $150.00 non-refundable deposit by above dates. Check the Academic Course for your student: Kinder Readiness Grade Level Review 1st-5th Middle School Study Skills 6th-8th Will student be attending St. Justin Summer Camp?YesNo Student InformationChild's Name First Last Grade completed in June 2015Please SelectK12345678DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgePlease enter a number from 4 to 15.Address Street Address City ZIP Code SexMaleFemalePrevious School AttendedName of school, city, and gradeHas child received special testing?Please SelectYesNoIf yes, what?What (if anything) was diagnosed?Has child ever been retained?Please SelectYesNoIf yes, what grade?Specific reason for sending child to summer school: Medical Information Authorization is hereby given to school officials to render emergency medical treatment for any serious injury or illness to my child in the event I cannot be reached at the time of accident or illness. I authorize emergency transportation of my child to a hospital if deemed necessary. Hospital I wish my child transported to:Policy NumberInsurance CompanyKnown allergies to medicationsDoctor NamePhoneDoctor NamePhoneFamily InformationChild lives with:Mother/Guardian's Name First Last Address Street Address City ZIP / Postal Code Home PhoneCell PhoneWork PhoneEmail Father/Guardian's Name First Last Address Street Address City ZIP / Postal Code Home PhoneCell PhoneWork PhoneEmail When parents cannot be reached, please notify:NamePhoneNamePhoneNamePhoneThese listed persons are also allowed to pick up the child. I wish to apply for admission of my child to the St. Justin Summer School Program. The information stated above is true and correct to the best of my knowledge. SignatureDate This iframe contains the logic required to handle Ajax powered Gravity Forms.