REGISTRATION FORM FOR JR HIGH SUMMER REACH FOR SUCCESS – Hillside School and Learning Center

Registration for JR High School Summer Reach for Success

Please note:

Please fill out the form below – fields with an asterisk (*) are required:

Student's Legal Name: *

First

Last

Gender *

Male
Female
Non-binary

Has the student attended Hillside before? *

Yes
No

If so, what year?

Grade in Fall 2025: *

Student Email *

Date of Birth: *

Parent/Guardian #1 Name: *

First

Last

Gender *

Male
Female
Non-binary

Relationship *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian #1 Email *

Primary Telephone Number: *

Cell Phone #: *

Parent/Guardian #2 Name:

First

Last

Gender

Male
Female
Non-binary

Relationship

Lives with student primarily?

Yes
No

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian #2 Email:

Primary Telephone Number:

Cell Phone #:

List 2 local alternatives to whch your child may be released if the above parent/guardian are unavailable. List name, relationship, phone. *

Please provide a personal email and NOT A SCHOOL EMAIL such as johndoe@lcusd.net

List any allergies or special medical information here: *

Does student have an IEP or 504? If yes, please include a copy with your registration *

Yes
No

Photo Release: I do/do not grant permission for my child's photo to be used for publicity purposes for The Hillside School & Learning Center. These photos will be used strictly for informational literature (e.g., website, press releases, and brochures). I acknowledge these photos are the sole property of Hillside and no compensation will be received. *

I do give permission
I do not give permission

Referred by: *

Initial Here: Summer Tuition $825. Tuition is to be paid within 5 business days of registration. *

(I/We have read and understand the tuition and fees.)

Initial Here: A non-refundable deposit of $200 will be kept if you drop a class for any reason. No refunds will be given after the 1st day of class. *

Method of Payment *

Pay by Credit Card - I will be calling the school office at 818.790.3044 to pay by credit card. (A 3.9% will be added to all credit card payments.)
Pay by Check - I will be dropping off a check at The Hillside School, 4331 Oak Grove Dr., La Canada, CA 91011. ($35 fee is charged for any returned check.)

Initial Here: I/We have read, understand and agree to the terms and conditions on this form. *

Additional Comments:

Name