Student Name:*

Student′s Birth Date:*

Student′s Grade:*

Desired Course(s):

Parent ⁄ Guardian Name:*

Home Phone:*

Cell Phone:*

Work Phone:*

Address:*

City:*

State:* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York 4 North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming

Zip:*

Emergency Contact Name:*

Emergency Contact Phone:*

Does the student have any allergies or other medical consideration?*

Yes

No  

If yes, all medicines must be left in the DLS office.

Students should be registered for DLS classes based on the grade level they will enter in the fall semester. DLS classes are designed to provide enrichment for Middle and High School Students during the summer through an interactive, facilitative workshop format.

There is a $100 deposit fee per class per student to hold a space in a class and is non-refundable. The payment is due in full on the first day. Space is limited.