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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