Mary Star of the Sea Summer School

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June 28-July 15 2021 8:30am-2:00pm
Monday-Thursday
No School July 5

Email *

Student Information

First Name *

Last Name *

Address *

Birthdate *

YYYY

Grade Level 2021-2022 *

Parent/Guardian Information

Name and Relationship *

Address *

Phone Number *

Emergency Contact

Other than Parent/Guardian

Name and Relationship *

Phone Number *

Health Information

Allergies *

Health Insurance Provider Name & Address *

Doctor's Name and Phone Number *

Dentist's Name and Phone Number *

Will you need daycare from 2pm-5pm at $15/day? *

Yes

Consent *

By checking this box and entering my name below, I understand that MSSE does not assume responsibility for payment of physician. However, in an emergency MSSE may choose physician. In an emergency, I give school personnel permission to have my child receive medical treatment.

Required

Today's Date *

YYYY

Parent Name as Signature *

Payment

$325/ student
Please make payments (cash, check, credit card) to the MSSE office by June 19
Checks payable to "Mary Star Elementary"

Send me a copy of my responses.

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