Salesianum Academic Summer Programs-2015
Registration Form
Please print clearly.
Student Name: ______Parent/Guardian Name: ______
Address: ______City: ______State: ______Zip Code: ______
Home Telephone: ______Parent E-Mail: ______Summer E-Mail (if different): ______
Please indicate course(s) in which you wish to enroll your son below:
Course No. Course Name Dates of Course Time (if applicable) Tuition
SC $
______
SC $
______
Total Tuition: _$______
Registration must be received no later than Monday, June 1. Tuition is due at time of registration. Checks should be made payable to Salesianum School and returned to the attention of Academic Summer Programs (1801 N. Broom Street Wilmington, DE 19802). Refund Policy: Cancellation before June 1 will yield a 75% refund. Cancellation after June 1 but before June 12 will yield a 50% refund. No refund will be given after June 12.
Students enrolled in a full day course should bring a lunch. Vending machines are available for beverages.
(Please complete reverse side of this form.)
Mother’s Name:______
Work Phone:______
Home Phone:______
Cell Phone: ______
Father’s Name:______
Work Phone:______
Home Phone:______
Cell Phone: ______
Emergency contact, if parents are not available: Relationship
Name and phone______
Student’s Doctor and Phone:______
Insurance Carrier:______
Policy Number:______
Medical conditions (asthma, diabetes, etc):______
Medication or other allergies: ______
Present medication and dosages (please list): ______
(Please administer all medication before or after coming to Salesianum. If medicine must be administered during the day, a parent will have to come to Salesianum to do so.)
Medical Authorization Statement
Please mark the following statement if you so authorize:
_____During my son’s participation in Salesianum Summer Programs, I authorize the administration of minor first aid to my son.
In the event that I cannot be reached in an emergency medical situation, I give permission to have my son transported to the nearest medical facility and for him to receive the necessary treatment by medical personnel.
Signature of Parent______Date______