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SAEP 2012 Registration

Your Information

Personal Information

*	First Name:
*	Last Name:
*	Relationship to student:
*	Address:
*	City:
*	State:	Select a stateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
*	Zip Code:
*	Home Phone:
	Work Phone:
	Cell Phone:
*	Email Address:

Emergency Contact Information

*	Emergency Contact Name:	Alternate name - you will be the first one we contact.
*	Emergency Contact Relationship:
*	Emergency Contact Phone:

Helpful Information

*	Carpool?	No Yes We are going to compile a list a parents who are interested in carpooling. If you select "yes", we will email you the names and phone numbers of other parents from the same zip code. We will not publish addresses- that will be up to you to give out that information. Select "yes" if you are interested.
	How did you hear about SAEP?	Select... A Friend SAPESS Library College Guidance Counselor Teacher Sibling Internet/Search Engine Other...

Student Information

Personal Information

*	First Name:
*	Last Name:
	Middle Name:
*	Birth Date:	mm/dd/yyyy
*	Gender:	M F

Program/Course Information

Select the grade this student will be in next fall 6th7th8th9th10th11th12th

	Program:
	3rd Period:	I would like to enroll this student in the 3rd period option ($200) As requested by many parents, we are able to offer an extension to our day. There will be a 20 minute supervised lunch period from 12:35-12:55. And from 1:00 to 2:00 there will be a supervised study hall.
	Absent Dates:	Please specify dates you plan to miss due to vacations or other obligations.
	Send Transcript:	Do you want your grades sent to the school you will attend in Fall? No Yes
*	Current School:
	School Next Fall:	(Leave blank if same as current school)

Add another student to this registration form

Registration Summary Registration Total: $0.00 Please carefully review the information you provided for yourself and your student(s) before submitting this registration form. You have two choices for payment method - online with a credit card through PayPal or by mailing in a check. If you choose the option below to pay online now using PayPal but change your mind after submitting this form, do not reregister, simply mail us a check. Comments or Questions: Payment Method: Online at PayPal Check by Mail I understand the following: Enrollment is not complete until payment and both pages of the release form are received for my student(s) Teacher requests cannot be honored. Due to the logistics of scheduling, students may be moved into different teacher's classes or periods. Academic program class closure policy: if not enough students sign up for a class, SAEP will close it in a timely manner and issue a full refund. Enrichment Program class closure policy: if a class closes either because of too many, or too few students, I will be asked to chose an alternate Enrichment course. No refund will be given.

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