REGISTRATION FORM FOR JUNIOR HIGH SUMMER REACH FOR SUCCESS

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REGISTRATION FORM FOR JR HIGH SUMMER REACH FOR SUCCESS

Student's Legal Name: *

First

Last

Date of Birth: *

Student's Email *

Present School Attending: *

Current Grade: *

High School Grad Year: *

Has Student Attended Hillside before?

Yes
No

If Yes, what was the last year attended:

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

Yes
No

Parent/Guardian #1 Name: *

First

Last

Home Phone #:

Cell Phone #: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Parent Email *

Work Phone #:

Parent/Guardian #2 Name: *

First

Last

Home Phone #:

Cell Phone #: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Parent Email: *

Work Phone #:

List 2 local alternatives to which your child may be released if the above parent/guardian are unavailable. List Name, Phone, Relationship *

List any allergies or special medical information here:

Referred By: *

In the event of a disaster, if parents or guardians are not available, my child may be released to an adult familiar to them. *

yes
no

In case of emergency, and if I/we cannot be reached, I/we the undersigned parent(s) or guardian(s) of the above named student, a minor, do hereby authorize a representative of The Hillside School and Learning Center and/or the alternates listed above to act as agent(s) to consent to any X-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care deemed advisable and rendered by any licensed physician or surgeon, whether in his/her office or in a licensed hospital. This authorization is given in advance of any required care to empower a representative or official of the The Hillside School and Learning Center to give consent for such treatment as the physician may deem advisable. I/we understand that The Hillside School and Learning Center does not provide accident medical insurance for students for school-related injuries.

Signature(s): The undersigned declare under penalty of perjury that they are the parent or legal guardians of the above named student and grant the above authorization. (Signature of both parents/guardians needed unless single parent or guardian with legal custody.) *

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

TUITION:
Semester Tuition: $775
A non-refundable $200.00 deposit per class will be kept if you drop a class for any reason. No refunds will be given after the 1st day of class.
Tuition is to be paid in full within 5 business days of registration. Terms and conditions are below. A convenience fee of 3.7% will be added to all payments made by credit card. A fee of $35 applies for returned checks.

Initial Here: *

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

Method of Payment *

Pay by Credit Card - I will be calling the school office at 818.790.3044 to pay by credit card. (A 3.7% will be added to all credit card payments.)
Pay by Check - I will be dropping off or mailing a check to: 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.)

Phone

THE HILLSIDE SCHOOL AND LEARNING CENTER IS FEDERALLY RECOGNIZED AS A 501(C)(3) TAX EXEMPT ORGANIZATION.

HILLSIDE SCHOOL AND LEARNING CENTER | 4331 OAK GROVE DR., LA CAÑADA, CA 91011 | 818-790-3044