Mansfield High School
Middle School / High School Summer School Program
REGISTRATION FORM
(Please Print)

Student's Last Name:  _________________________  First Name:  _____________________________

Address: ___________________________  City: ________________ State: _____  Zip Code: _______

Grade Just Completed:  ___________  School Student Attends:  ________________________________

Parent/Guardian Name: ________________________________________________________________

Home Phone:  ______________________________ Work Phone: ______________________________

Which phone number should be called during class time?  _____________________________________

Emergency Contact:  _________________________  Phone:  __________________________________

Special medical concerns: ______________________________________________________________

Transportation - How will student get to and from classes? ____________________________________

Please note: No refunds will be issued if a student is dismissed from the program.

I have read and understand the Statement of Policy and Program Expectations.  I will follow all the policies of the Mansfield High School Summer School Program.

_______________________    __________       _______________________     _______
       Student Signature                       Date                       Parent Signature                   Date