Student's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Student's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Name

Nombre de mamá

First Name

Last Name

Mother's Cell

(###)

###

####

Father's Name

Nombre de papá

First Name

Last Name

Father's Cell

(###)

###

####

Emergency Contact

Contacto en caso de emergencia

First Name

Last Name

Phone *

(###)

###

####

By checking here You agree to: *

Al marca esta casilla usted acepta a:

an interview with the program director and your child; una entrevista con la directora del programa con su hija

bring: recent report cards, insurance, and deposit of $25 per student; traer, calificaciones, seguro medico y $25 de deposito por niña.

Grades in Reading

Calificaciones in Literatura 10 Bueno, 1 Malo 10 is Good, 1 is Bad

10 - Gets A's, loves to read

9

8

7

6

5

4

3

2

1 - Fails, hates to read

Grades in Math *

Calificaciones in Literatura 10 Bueno, 1 Malo 10 is Good, 1 is Bad

10 - Gets A's, loves to read

9

8

7

6

5

4

3

2

1 - Fails, hates to read

Grades in Science *

Calificaciones in Literatura 10 Bueno, 1 Malo 10 is Good, 1 is Bad

10 - Gets A's, loves to read

9

8

7

6

5

4

3

2

1 - Fails, hates to read

Effort in School *

Calificaciones in Literatura 10 Bueno, 1 Malo 10 is Good, 1 is Bad

10 - Good study habits, always trying

9

8

7

6

5

4

3

2

1 - Never studies without discipline

Behavior in School *

Comportamiento en Escuela 10 Bueno, 1 Malo 10 is Good, 1 is Bad

10 - Respects others, never suspended, never absent without good cause

9

8

7

6

5

4

3

2

1 - Suspended multiple times, does not want to be in school, often absent

Preferred Interview Date

- Best Date to come in for interview (no Sundays) - Mejor fecha para venir a la entrevista (no domingos)

MM

DD

YYYY

Preferred Interview Time *

- Best Date to come in for interview (no Sundays) - Mejor fecha para venir a la entrevista (no domingos)

Hour

Minute

Second

AM PM

Best Phone # to reach you *

(###)

###

####

By checking you agree to:

Al marca esta casilla usted acepta a:

Come with your son for an interview; Ven con tu hijo a una entrevista

Bring a copy of a recent report card to the interview; traer calificaciones

Bring a deposit of $25; traer $25 de deposito

Student's Name *

Nombre del estudiante

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Student's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Name

Nombre de mamá

First Name

Last Name

Mother's Cell Number *

Numero de telefono de mamá

(###)

###

####

Father's Cell Phone *

Numero de teléfono de papá

(###)

###

####

Emergency Contact *

Contacto en caso de emergencia

First Name

Last Name

Phone *

(###)

###

####

By checking You agree to: *

Al marca esta casilla usted acepta a:

an interview with the program director and your child; una entrevista con el director del programa con su hijo.

bring: recent report cards, insurance, and deposit of $25 per student; traer, calificaciones, seguro medico y $25 de deposito por niño

Grades in Reading *

Calificaciones in Literatura - 10 Bueno, 1 Malo 10 is Good, 1 is Bad

10 - Gets A's, loves to read

9

8

7

6

5

4

3

2

1 - Fails, hates to read

Grades in Math *

Calificaciones de matematicos - 10 Bueno, 1 Malo 10 is Good, 1 is Bad

10 - Gets A's, loves to read

9

8

7

6

5

4

3

2

1 - Fails, hates to read

Grades in Science *

Calificaciones de sciencia 10 Bueno, 1 Malo 10 is Good, 1 is Bad

10 - Gets A's, loves Science

9

8

7

6

5

4

3

2

1 - Fails, hates Science

Effort in School *

Esfuerzo en escuela 10 Bueno, 1 Malo 10 is Good, 1 is Bad

10 - Good study habits, always trying

9

8

7

6

5

4

3

2

1 - Never studies until disciplined

Behavior in School *

Comportamiento en escuela 10 Bueno, 1 Malo 10 is Good, 1 is Bad

10 - Respects others, never suspended, never absent without good cause

9

8

7

6

5

4

3

2

1 - Suspended multiple times, does not want to be in school, often absent

Best Date for Interview *

- Best Date to come in for interview (no Sundays) - Mejor fecha para venir a la entrevista (no domingos)

MM

DD

YYYY

Best Time for Interview *

Best interview time for you and your daughter El mejor tiempo de entrevista para usted y su hija

Hour

Minute

Second

AM PM

Best Phone # to reach you *

Mejor numero de telefono contactar usted

(###)

###

####

By checking you agree to:

Al marca esta casilla usted acepta a:

Come with your son for an interview; Ven con tu hijo a una entrevista

Bring a copy of a recent report card to the interview; traer calificaciones

Bring a deposit of $25; traer $25 de deposito