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SUMMER ADVENTURE APPLICATION
Monday, June 18, 2018 - Friday, July 20, 2018
8:30 am - 12:30 pm (closed July 4)
ROOSEVELT ELEMENTARY SCHOOL
* Required Field
STUDENT'S FULL NAME
*
GENDER
*
GRADE in AUG.
*
Date of Birth
*
Home School
*
Age
*
Indicate class
number
and
title
of 1st and 2nd choices below (please note: some classes are full morning classes)
Full Morning Classes: 8:30 - 12:30
Full-Morning Class # and Title (1st Choice)
Full-Morning Class # and Title (2nd Choice)
Period I: 8:30 - 9:40
Period I Class # and Title (1st Choice)
Period I Class # and Title (2nd Choice)
Period II: 9:55 - 11:05
Period II Class # and Title (1st Choice)
Period II Class # and Title (2nd Choice)
Period III: 11:20 - 12:30
Period III Class # and Title (1st Choice)
Period III Class # and Title (2nd Choice)
DEPENDING ON ENROLLMENT, SOME CLASSES MAY BE CLOSED. WE WILL MAKE EVERY EFFORT TO ENROLL YOUR CHILD IN THE CLASSES OF YOUR CHOICE.
AGREEMENT
Please enroll my child in the Summer Adventure Program. Classes are offered subject to enrollment. Except when team taught, classes will be limited to no more than 25. Enrollment will continue until classes are full. Confirmation of classes will be sent to parent/guardian’s email or home address in mid- to late April. We charge $6 per student when a credit card is used for payment.
Tuition Refund Policy
*
YES
I have read and understand the Tuition Refund Policy
as outlined on page 1 of the Summer Adventure brochure.
I plan to apply for a scholarship. I have read and I understand the process for scholarship application as outlined on page 1 of the Summer Adventure brochure. I am uploading my child's free or reduced lunch eligibility notification below or I will send separately. Note: if you cannot upload your eligibility letter below, please click this check box and either email your student’s letter to elementary@summer-adventure.org, mail a copy, or bring it to the Summer Adventure office.
YES
Upload free/reduced lunch eligibility letter (if applicable)
CHECK ONE:
My child is currently enrolled in a SMMUSD school.
YES
My child is new to SMMUSD but is already enrolled in a SMMUSD school for the 2018-19 school year.
YES
My child is not enrolled in a SMMUSD school for the 2018-19 school year. Attached is his/her proof of age (birth certificate, passport, or similar official document.) Note: if you cannot upload proof of age below, please click this checkbox and either email your student’s proof of age to elementary@summer-adventure.org, mail a copy, or bring it to the Summer Adventure office.
YES
Upload proof of age (if applicable).
By typing your name below, we consider this your electronic signature.
SIGNATURE OF PARENT/GUARDIAN
*
DATE
*
PAYMENT INFORMATION:
Payment of FULL AMOUNT is required at time of registration.
Full morning or 3-period payment
🛈
$550 for payments made after April 13
$525 for payments made on or before April 13
1 or 2 classes payment
🛈
$405 (2 classes)
$210 (1 class)
Materials Fees Total
🛈
Enter the materials fees for your
first choice classes.
Scholarship Amount
for Free/Reduced Lunch
🛈
Payment is $75 (Free Lunch Students) or
$200
(Reduced Lunch Students).
I have uploaded
my students’ eligibility notification letter above, or
I will submit my student’s eligibility notificatio
letter it to the Summer Adventure Office.
Application for Scholarship
$75.00
My student is not on free or reduced lunch,
but I would like to apply for a scholarship.
Sponsor a Scholarship Student
🛈
I want to help by sponsoring a scholarship
student with a tax-deductible contribution
(please enter amount in box).
Form of Payment
*
Credit Card
eCheck
Credit Card Convenience Fee
*
$6.00
Please check the box to acknowledge that you agree
to be charged a $6 credit card convenience fee.
Current Total:
$0.00
Calculate
Press 'calculate' to see your total.
Card Type
*
Visa
Mastercard
Name on Card
*
Billing Address
*
Billing City, State, Zip
*
Credit Card Number
*
Expiration Date
*
CVV
*
Bank Account Type
*
Personal
Business
Please be certain the account
infor
mation
is accurate
and there are sufficient
funds
available.
If your account
information is
inaccurate or is rejected by your bank for any
reason you will be charged a $25 fee to cover
our costs of
the rejected payment.
Nine-digit ABA Routing Number
*
Bank Account Number
*
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