Excell Program Spring 2022 Student Application & Agreement
Please Note: if you have more than one student that you are registering, you will need to submit a separate application for each student

The complete application includes:
(A) The Excell program's policies and procedures (Excell rules) is included
(B) The Release of All Claims for Excell Participation is included herewith

Should you have any problems filling out this application, please email, admin-excellregistration@lacbpe.org for assistance
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Email *
Student First Name *
Student Last Name *
Grade Level *
Gender *
Math Class (Choose One) *
Science Class (Choose One) *
SAT Class? *
Choose yes or no. This is generally for grades 10 and up. Please note: If you choose "yes" your student will forego the science class for the SAT Prep Class.
Date of Birth *
MM
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DD
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YYYY
Address *
City *
State/Province *
Zip/Postal Code *
School Name *
Please list significant medical problems this student may have:
How did you learn about the program?
Parent or Guardian Contact Information
For any questions that are not applicable, type N/A.
First Point of Contact *
Relationship to Student (Mom, Dad, etc)
First Name *
Last Name *
Home Phone
Cell Phone *
Work Phone
Email *
This will be used to send Zoom information
Second Point of Contact
Relationship to Student (Mom, Dad, etc)
First Name
Last Name
Home Phone
Cell Phone
Work Phone
Email
Emergency Contact Information
Emergency Contact First Name *
Emergency Contact  Last Name *
Emergency Contact phone number *
Emergency Contact relationship to student *
Siblings enrolled in the EXCELL program
If you will be enrolling multiple children in the program, you will need to fill out an application for each child.
Name and grade of any sibilings enrolled in the EXCELL program (you must fill out a separate application for EACH child)
Example: John Doe, 7 Casie Allen, 10
Program Cost per student
$85 for one student; $65 for each additional sibling. Payment is due the first day of the session. Once you complete this form, you will receive a confirmation email. See lacbpe.org for the session schedule.
Amount for this student: *
Total Number of Students: *
Date *
Use the drop down arrow to specify the date that the application was completed
MM
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