Please print out this form, complete and mail or FAX
to Saturday Academy.
An
Adobe Acrobat (pdf) file of this application is also available. Click here to access this file.
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Please print clearly ~
Student Information:
_________________________________________
Student Name
Male
Female
_________________________________________
Home Phone
Student E-Mail
_________________________________________
Date of Birth / Grade (Fall 2003)
School
_________________________________________
Parent #1/Guardian Name
Day/Cell Phone
_________________________________________
Employer
Work Phone
_________________________________________
Parent #2 / Guardian Name
Day/Cell Phone
_________________________________________
Employer:
Work Phone
Class Information:
_________________________________________
Class (first choice)
Section #
_________________________________________
Class (second choice)
Section #
I would like to take both
classes
Why do you want to take this class? (If class
has prerequisites, include qualifications)
_________________________________________________________________________
Special needs/equipment. (Please allow
two weeks notice) _________________________________________________________________________
Do you have any special
conditions we should know about?
_________________________________________________________________________
Emergency Medical Form:
I hereby give consent to
treat _____________________________________ in case of a medical
emergency. In understand that all efforts will be made to contact
me immediately.
Signature of parent or guardian: Name:_____________________________________________________Date:___________
IN CASE OF EMERGENCY: Phone number where we can reach you when your child will be
in class: ____________________
Person to contact if we are unable to reach you:
Name:_________________________________Phone:_______________________
Relationship to Child:__________________________________________________
Media
Release: Occasionally we take photos or video footage
during class for use in our catalog and other public media. Do we
have your permission to use your child's image?
Yes
No
Street Address: _______________________________________________
City _____________________________State____ Zip:_______________
Please check programs you have participated in:
Classes
ASE
AWSEM
SWRP
LEAP
Tuition Options (please check one): Check Enclosed $__________
(amount) Credit card authorization
(fill out below)
Tuition assistance form requested (one class per student per term) See Application
Policies and Procedures on Page 22. Donations: I would like to join the Scholar Society by
donating $50 or more
Tax deductible contribution of $____________________
_____________________________________________________________
Cardholder’s name as it appears on card (please print
legibly)
_____________________________________________________________
Authorized Signature / Date
All charges are processed as PSU Saturday Academy
Optional Information: Some of Saturday Academy’s costs are underwritten
by generous foundations, corporations, and individuals. They ask that
we supply statistical information about the students we serve. Responses
will be kept strictly confidential. Please mark all that apply:
