The Beverly Institute
E-
Summer School / After
School Registration Form
School Year: ________
Today is:
___________
Student Information School
Student # ______________________
High
School Graduation Date: ___________
Child’s Name: ____________________________________Age:
______ Sex: ______ DOB: _________ Grade: ________
Birth Country: ____________________________________
Race: _____ Primary Language: ________________________
Address:
Email Address:
______________________________________________________________________________________
(Please
use email address that you wish to receive information about your school work)
Parent Information
Parent(s)
Name: ____________________________________________________________________________________
Mother: Cell Number:____________________
Work Number: ____________________
Email Address:
______________________________________________________________________________________
(Please
use email address that you wish to receive information about your child’s
school work)
Father: Cell Number:____________________ Work Number: ____________________
Email Address:
______________________________________________________________________________________
(Please
use email address that you wish to receive information about your child’s
school work)
Legal Guardian:
______________________________________________________________________________
Academic Information
Student’s Current school: ____________________________________________________________________________
Address:
School Office Number:
_________________________________ Fax Number: __________________________________
Will transfer to another school upon
finishing summer school? __ Yes __ No;
if yes, School Name: __________________
Complete: Fill in Course Name and select which semester
you need. Course 1st Semester 2nd Semester 1 2 3 4
Information
Check all
that apply:
o
After School
Program
o
Summer School
o
Grade Forgiveness
o
Tutoring (Just
need more practice)
o
Take a course to
get ahead
Office Use
Only Student Account: User Name: _______________________________ Password: ________________________________ FLVS Student Number: ______________________ Parent (Guardian
Account) User Name: _______________________________ Password: ________________________________
Check One:
o
Session A: 8:00 –
12:00 pm
o
Session B: 1:00 –
5:00 pm
o
Session C: 6:00 –
9:00 pm