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2022 Summer Enrichment Form
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* Indicates required question
Family Name(s)
*
Your answer
Street
*
Your answer
Apartment/Floor/Unit Number
*
Your answer
City
*
Your answer
State
*
New Jersey
New York
Pennsylvannia
Other:
Zip Code
*
Your answer
Are you a enrolled or current student of St. Leo's?
*
Yes
No
Student's Name (First Child)
*
Your answer
Student Date of Birth (First Child)
*
MM
/
DD
/
YYYY
Any medical concerns?
*
Your answer
Student's Grade (First Child for September 2022)
*
4th Grade
5th Grade
6th Grade
7th Grade
Workshop Selection
*
Leadership (8 am to 10 am)
STEAM (10:30 am to 12:30 pm)
Both
Required
Please select all weeks attending
*
6/27
7/5 (T-F) Only
7/11
7/18
Required
Student's Name (Second Child)
Your answer
Student's Date of Birth Second Child)
MM
/
DD
/
YYYY
Any medical concerns?
Your answer
Student's Grade (Second Child for September 2023)
4th
5th
6th
7th
Clear selection
Workshop Selection
Leadership (8am to 10 am)
STEAM (10:30 am to 12:30 pm)
Both
Clear selection
Emergency Contact # 1 Name
Your answer
Emergency Contact # 1 Relationship to child
Your answer
Emergency Contact #1 Cellular Phone Number
Your answer
Emergency Contact # 2 Name
Your answer
Emergency Contact # 2 Relationship to child
Your answer
Emergency Contact #2 Cellular Phone Number
Your answer
Registration will not be considered complete until this form is completed and your $50.00 deposit per family. REGISTRATION FEES ARE NON-REFUNDABLE
*
I agree
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