Download REGISTRATION FORMS BLAIR SUMMER 2016

Blair Summer Achievement Academy
Registration Form
To be completed by PARENT/GUARDIAN. Please print all information in ink.
PART I: STUDENT INFORMATION
Student ID # ___________________
Session ___1 and ___2
Grade in Sept: _________
Student’s Name: ______________________________________________________________________________
Parent/Guardian’s Name: _______________________________________________________________________
Address: ____________________________________________________________________________________
Home Phone: _______________________________
Cell Phone: ________________________________
Emergency Contact
Emergency Contact
Name: ____________________________________
Phone Number:______________________________
Parent Email:______________________________________________________________________________________________
Part II: REGISTRATION
Algebra I: ______________________________
Geometry: _____________________________
Algebra II: _________________________________
Part III: PAYMENT OF TUITION— Attach check, money order, or pay with credit card through the school’s Online School Payments website
Tuition Amount $ __________ ☐ Cash ☐ Check # _________ ☐ Money Order # ___________ ☐ Charge
Make checks and money orders payable to MBHS
Credit/debit card payments must be completed through the school’s Online School Payments website
There will be a $3.75 convenience charge.
http://osp.osmsinc.com/MontgomeryMD/BVModules/CategoryTemplates/Detailed%20List%20with%20Properties/C
ategory.aspx?categoryid=BY308
Part IV: APPLICATION for PARTIAL WAIVER of SUMMER SCHOOL TUITION
If applying for waiver, please attach ONE of the following:




All W-2 forms for tax year 2015
The FIRST PAGE of the family’s tax return
Copy of a current letter from a family assistance agency
Notarized statement of income from self-employment or
other sources of income
If your income is:
You pay:
$0 - $30,866 or copy of letter from a
family assistance agency
__$85
$30,867 - $44,123
__$120 ☐
Over $44,124 (full tuition)
__$300 ☐
☐
PART V: PARENT’S /GUARDIAN’S SIGNATURE: Parent’s/guardian’s signature certifies that:
 Student is authorized to enroll in the local summer school program
 I certify that all of the above information is true and that I have attached the required verification document. I understand
that school officials may verify the information on this application.
 Method of payment is assured, and it is understood that a $25.00 fee will be assessed for returned checks
____________________________________________
Signature, Parent/Guardian
____/____/____
Date