Peicy }ulian Acauemy Eniollment Foim (S2u14) Page 1 of 2

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(To be completeu by the paient oi guaiuian)



Stuuent's LEuAL Name


_________________________________________________________________________________________________________________________________________________
5+61 7+0" 4*#61 7+0" 8*//)" 7+0"
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___________________________________________________________________________________________________________________________________________
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!#33J 3J 9*#1: Please check appiopiiate box:
Biith Ceitificate ! Affiuavit ! School Recoius !













Stuuent's Name"#$%&' (') *+,-(./0,' KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK uiaue1&/(#___________ B0BFec.Nac._ ______________________











0ffice 0se 0nly

Start Date_________________


Session___________________
___
B3,1+$1 @,J3#0+1*3,
831:"#L6 7+0"M Cell#: Woik#:
2G0+*)M
4+1:"#L6 7+0": Cell#: Woik#:
2G0+*)M
5"E+) ?(+#/*+,=N1:"# Cell#: Woik#:
2G0+*)M

7"+#O% A")+1*P"Q 7"*E:O3# 3# ;+% B+#" D"#63, that can caie foi chilu if neithei paient can be locateu.

__________________________________________________________________________________________________________________________
Name Auuiess Telephone
9% $3(#1 3#/"#Q 1:*6 $:*)/ 0+% ,31 O" )"E+))% #")"+6"/ 13MKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK




B+0D -"66*3,

Please select the session(s) in which you wish to enioll youi chilu. If you want to enioll in moie than one session please
select all boxes that apply.

-"66*3, RS -"66*3, RT
! '(," UQ TVSW X '()% YQ TVSW ! '()% ZQ TVSW X .(E(61 SQ TVSW
-"66*3, RY
! .(E(61 WQ TVSW X .(E(61 TUQ TVSW

.//*1*3,+) -"#P*$"6M
! Noining Supeivision: 7:1S - 9:uu AN ($Su pei chilu)
Infinity anu Beyonu Tutoiing has sepaiate application anu fee. Please contact S62-49S-74uu foi uetails
Peicy }ulian Acauemy Eniollment Foim (S2u14) Page 2 of 2













Is Neuication taken iegulaily. Yes ! No !___________________________________________________________________________





















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Special Euucation: ! Resouice (RSP) ! Special Bay Class (SBC) ! SpeechLanguage ! Su4 Accommouation Plan

0thei ! uifteu (uATE) ! Remeuial Nath ! Remeuial Reauing ! Counseling


-1(/",1L6 7+0" KKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKKK ;N9 KKKKKKKKKKKKKK ?#+/" KKKKKKK


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1. _________________________________________________ 2. _______________________________________________________ S.___________________________________________________
20"#E",$% 8"/*$+) .(1:3#*H+1*3,
I amwe aie the paientguaiuian of the above nameu stuuent. In case I amwe aie unable to be ieacheu uuiing any
emeigency, Iwe heieby authoiize a iepiesentative of the acauemy puisuant to the piovisions of Family Coue Section
691u, to act as an agent to consent to the giving of any anu all meuical, uental, hospital oi suigical caie to the above
nameu stuuent. Yes ! No !

B+0D !+%0",1

$6uu payment pei session in full (no uiscounts) *
$Su non-iefunuable ueposit *

N0TE: Aftei submitting this application you will:
23 Be uiiecteu to oui secuie online payment piocessoi Paypal
43 Receive eniollment confiimation email






! Bigh school giauuate
Iwe have ievieweu this uocument anu to the best of my knowleuge, the infoimation containeu heiein is tiue anu
complete. The unueisigneu ueclaies unuei penalty of peijuiy that they aie the paients oi legal guaiuians of the above
nameu stuuent anu giant the above authoiizations.
Iwe have ieau the Camp Policies anu Pioceuuies, the Release anu Waivei of Liability anu Inuemnity Agieement,
Photoviueo Authoiization anu Release Waivei, anu I agiee to ALL of the teims anu policies.


Parent/Legal Guardian Signature Date:

_"+)1: !#3O)"06 <B:"$] +)) 1:+1 +DD)%>

! Biagnoseu ABB oi ABBB ! Bistoiy of Fiactuies ! Chicken Pox ! Autism

! Asthma ! Bistoiy of Bospitalization ! Scoliosis ! Physical Banuicap

! Blauuei Pioblems ! Bistoiy of Suigeiy ! Bypoglycemia

! Bleeuing Bisoiuei ! Known Beaiing Loss ! Beau Injuiy

! Coloi vision Beficiency ! Known vision Loss ! Beat Pioblem

! Biabetes ! Physical Limitations ! Bistoiy of Eai Pioblem

! EczemaSkin Tiouble ! Weai Contact Lens ! Weai ulasses

! Epilepsy ! Eye Injuiy ! Fiequent nosebleeus

! Seizuie Bisoiuei ! Alleigies ! Neuication to be taken at school

0thei oi fuithei uetails of above5 _____________________________________________________________











0thei oi fuithei uetails of above: __________________________________________________________________________________________________________________