Dear Parent/Guardian and Applicant

Thank you for your interest in our After School Stem-‐R-‐Us Tutorial Program. Please fill out the application form completely. Your child will not be enrolled for the 2015 After School Stem-‐R-‐Us Tutorial Program until tutorial fees are made in the form of a check or money order payable to Stem-‐R-‐Us.

I understand that tutorial fees are payable in advance of services. I understand that no refunds will be given for any reason. Should I wish to withdraw my child from the program, I agree to give two weeks written notice prior to the last day to the person in charge. If notice is not received as stated above, the full payment for tutorials will be expected.

Student First Name

Student Last Name

Age

2nd Studnet Full Name

2nd Age

3rd Student Full Name

3rd Student Age

Address 1

Address 2

City

Zip / Post Code

Phone

Student School

School District

Mother's First Name

Mothers Last Name

Mothers Cell Phone Number

Mothers Email

Fathers First Name

Father's Name

Fathers Cell Phone Number

Father's Email

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone

Emergency Contact Email

2nd Emergency Contact First Name

2nd Emergency Contact Last Name

2nd Emergency Contacts Phone

2nd Emergency Contact Email

Student Application

Dear Parent/Guardian and Applicant

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