PARENT REGISTRATION                                                "Back on Track" Academic Intervention Program      
Please complete the form below...
Session 2 will begin the first week of February and will run consecutively except for February break.

Classes are at St. Edmund's Hall.
Tuesday 4-5:00 ELA
Thursday 4-5:00 Math

Cost $200 (per student) for 10 classes of either ELA or Math.
Bring payment to the first day of class.
Contact Mary D'Emic at Mdemic914@gmail.com or text message to 917-288-8681.

Email *
Parent name(s) *
Parent phone number(s) *
Address *
List name of child / children and grade level (s) *
Class Preference (ELA - Math or both)
Please indicate any health issues that we need to be aware of -- otherwise state none. *
List (2) emergency contact numbers for the time(s) you child will be in session.  Include name and relationship to the child (children) *
Any other information or questions.
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