Class of 2021 Fresh Start Registration
Fresh Start Dates: June 12 through June 29, 2017

Registration and fee of $170 are due by Friday, April 21, 2017.
Online payments can be made at http://bit.ly/lockportepay.

Student's Name:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Parent(s)/Guardian(s) Name:
Your answer
Address:
Your answer
City:
Your answer
State:
Your answer
Zip Code:
Your answer
Home Phone Number:
Your answer
Cell Phone Number:
Your answer
Work Phone Number:
Your answer
Emergency Contact Name:
Your answer
Emergency Contact Phone Number:
Your answer
Allergies/other medical conditions:
Your answer
Please provide an email address for receipt of registration:
Your answer
T-shirt Size (adult sizes):
Are you interested in the free transportation option?
There will be field trips during the Fresh Start session where bus transportation will be provided. Please check the box below to give your student permission to participate in these field trips.
Required
Due to popular demand for the Fresh Start program, the policy is no refunds after May 1, 2017.
Required
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