Summer Academics Registration

*Student’s First Name

*Student’s School

*Student’s Last Name

*Grade Going Into

*Parent/Guardian’s First Name

*Parent/Guardian’s Last Name

*Mailing Address

*City

*State

*ZipCode

*Cell

Work

*Parent/Guardian’s Email

Emergency Contact Information

*Adult First Name

*Adult Last Name

*Relation to the Student

*Adults Cell

Adults Work

Alternative Contact

Alternate First Name

Alternate Last Name

Relationship to Student

*Alternative Cell

Alternative Work

*Please list all your child’s allergies

*If an emergency occurs, do we have your permission to take your child to the hospital?

Yes

Doctor’s Name

Doctor’s Phone

Preferred Hospital/Clinic

Registration Fee

I am committed to paying a registration fee as part of the enrollment process because my child’s education is worth investing in. I understand the registration fee is non-refundable.

*To complete the enrollment process, I agree to pay the registration fee by

Parent/Guardian Authorization

*My child will be picked up by

*Relationship to the Student

*Parent/Guardian signature

*Date

In the event that neither I nor the alternate contact listed above can be reached in an emergency, I authorize the attending physician to administer proper and necessary treatment for the safety of my child.

*Parent/Guardian signature

*Date

I authorize Notre Dame Urban Education Center to use photographs or video clips of my child and/or survey my child either through interviews or questionnaires for publicity purposes or data collection.

*Parent/Guardian signature

*Date

Summer Academics Registration

Summer Academics Registration

Emergency Contact Information

Alternative Contact

Registration Fee

Parent/Guardian Authorization

The Sisters of Notre Dame

Our Center

Contact Info