Excell Program Spring 2017 Student Application & Agreement
Please Note: if you have more than one student that you are registering, you will need to submit a separate application for each student

The complete application includes:
(A) The Excell program's policies and procedures (Excell rules) is included
(B) The CSUDH Release of All Claims for Excell Participation is included herewith

Should you have any problems filling out this application, please email, alexis.darcel.allen@gmail.com for assistance.

Student First Name
Your answer
Student Last Name
Your answer
Gender
Grade Level
Math Class (Choose One)
Science Class (Choose One)
SAT Class?
Choose yes or no. This is generally for grades 10 and up. Please note: If you choose "yes" your student will forego the science class for the SAT Prep Class.
Date of Birth
MM
/
DD
/
YYYY
Address
Your answer
City
Your answer
State/Province
Your answer
Zip/Postal Code
Your answer
School Name
Your answer
Please list significant medical problems this student may have:
Your answer
How did you learn about the program?
Your answer
Parent or Guardian Contact Information
For any questions that are not applicable, type N/A.
First Point of Contact
Relationship to Student (Mom, Dad, etc)
Your answer
First Name
Your answer
Last Name
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Work Phone
Your answer
Email
Your answer
Second Point of Contact
Relationship to Student (Mom, Dad, etc)
Your answer
First Name
Your answer
Last Name
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Work Phone
Your answer
Email
Your answer
Emergency Contact Information
Emergency Contact First Name
Your answer
Emergency Contact Last Name
Your answer
Emergency Contact phone number
Your answer
Emergency Contact relationship to student
Your answer
Siblings enrolled in the EXCELL program
If you will be enrolling multiple children in the program, you will need to fill out an application for each child.
Name and grade of any sibilings enrolled in the EXCELL program (you must fill out a separate application for EACH child)
Example: John Doe, 7 Casie Allen, 10
Your answer
Program Cost per student
$85 for one student; $65 for each additional sibling. Payment is due the first day of the session. Once you complete this form, you will receive a confirmation email. See lacbpe.org for the session schedule.
Amount for this student:
Total Number of Students:
Excell Rules Agreement
If you would like to print a copy, right-click and choose print.
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms