STUDENT NAME

AGE                                                                 BIRTHDAY

SCHOOL                                                         HOME SCHOOL

ENTERING GRADE SEPT 2010

ALLERGIES?

PARENT NAMES

ADDRESS

HOME PHONE                                                CELL PHONE
                                                                 (in case of emergency)

PARENTS’ email

SESSION         JUNE 14_______                        AUGUST 2 _______                                                                                                   
                         JUNE 21 _______                       AUGUST 23______

                         JUNE 28 _______                       AUGUST 30______

                    JULY 26 _______

Tuition cost per session is $175.

A $50. DEPOSIT CHECK MADE OUT TO LUCRETIA ROBBINS IS ENCLOSED._________  

Mail to:
Lucretia Robbins