Attachment C
Cedar Grove Elementary School
LOCAL SUMMER SCHOOL PROGRAM – July 11, 2016 – July 29, 2016
To be completed by PARENT/GUARDIAN. Please print all information in ink.
PART I: STUDENT INFORMATION
Student ID #: ___________________
Current Grade: ____________
Student’s Name: ______________________________________________________________________________
Parent/Guardian’s Name: _______________________________________________________________________
Address: ____________________________________________________________________________________
Home Phone: _______________________________
Cell Phone: ________________________________
Emergency Contact
Name: ____________________________________
Emergency Contact
Phone Number:______________________________
Part II: REGISTRATION
Course Name: Cedar Grove Summer School
☒Non-Credit
☐Credit
☐Failure
Part III: PAYMENT OF TUITION— Attach check, money order, or pay with credit card through the school’s Online School Payment website
Tuition Amount $ __________ ☐ Cash ☐ Check # _________
☐ Money Order # ___________ ☐ Charge
Make checks and money orders payable to Cedar Grove Elementary School
Credit/debit card payments must be completed through the school’s Online School Payment website.
Part IV: APPLICATION for PARTIAL WAIVER of SUMMER SCHOOL TUITION
If applying for waiver, please attach ONE of the following:
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All W-2 forms for tax year 2014
The FIRST PAGE of the family’s tax return
Copy of a current letter from a family assistance agency
Notarized statement of income from self-employment or
other sources of income
If your income is:
You pay:
$0 - $31,359 or copy of letter from a
family assistance agency
$85.00 ☐
$31,360 - $44,863
$120.00 ☐
Over $44,864 (full tuition)
$300.00_☐
PART V: PARENT’S /GUARDIAN’S SIGNATURE: Parent’s/guardian’s signature certifies that:
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Student is authorized to enroll in the local summer school program.
I certify that all of the above information is true and that I have attached the required verification document. I understand
that school officials may verify the information on this application.
Method of payment is assured, and it is understood that a $25.00 fee will be assessed for returned checks.
____________________________________________
Signature, Parent/Guardian
____/____/____
Date