Mary Star of the Sea Summer School
June 28-July 15 2021 8:30am-2:00pm
Monday-Thursday
No School July 5
Email *
Student Information
First Name *
Last Name *
Address *
Birthdate *
MM
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DD
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Grade Level 2021-2022 *
Parent/Guardian Information
Name and Relationship *
Address *
Phone Number *
Emergency Contact
Other than Parent/Guardian
Name and Relationship *
Phone Number *
Health Information
Allergies *
Health Insurance Provider Name & Address *
Doctor's Name and Phone Number *
Dentist's Name and Phone Number *
Will you need daycare from 2pm-5pm at $15/day? *
Consent *
Required
Today's Date *
MM
/
DD
/
YYYY
Parent Name as Signature *
Payment
$325/ student
Please make payments (cash, check, credit card) to the MSSE office by June 19
Checks payable to "Mary Star Elementary"
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