Course for Credit Registration Summer 2019
All sections must be filled out.
Student's Full Legal Name *
Your answer
Student's Preferred Name
Your answer
Student's Date of Birth *
MM
/
DD
/
YYYY
Student's email *
Put n/a if not applicable
Your answer
Student Phone Number *
Put n/a if not applicable
Your answer
Name of Primary Contact Parent/Guardian *
Your answer
Relation to student *
Your answer
Primary Contact email *
Your answer
Primary Contact Preferred Phone Number *
Your answer
Type of Phone
Primary Contact Alternative Phone Number
Your answer
Alt. Type of Phone
Second Contact Parent/Guardian
Your answer
Second Contact Relation to student
Your answer
Second Contact email
Your answer
Second Contact Preferred Phone Number
Your answer
Second Contact Type of Phone
Second Contact Alternative Phone Number
Your answer
Type of Phone - Alt.
Home Address(es) *
Your answer
Emergency Medical Information
Your answer
Emergency Contact if Parents are Unavailable *
List at least one person and their phone number
Your answer
Person(s) Responsible for Billing *
Your answer
Billing Contact's Phone Number *
Your answer
Email Address for Invoices *
Your answer
Grade for School Year 2019 - 2020 *
Name of School Student is Currently Attending *
Your answer
Course(s) Interested in Taking *
**If any courses are grade replacement, please make a note of that. If taking one semester of a year-long course, indicate which semester, first (A) or second (B). For instance, if taking grade replacement for second semester Geometry, write "Geometry B Grade Replacement" or "Geometry B GR."
Your answer
Interested in shared or group class? *
Check all that apply. We can't guarantee that a shared or group class can be put together during the summer due to scheduling constraints.
Required
Schedule Request *
Please make note of any vacations, preference of morning vs afternoon, number of days per week, etc., if known.
Your answer
Teacher Preference(s)
Your answer
By submitting this form, you acknowledge that all information provided is accurate and agree to The Privett Academy's Fees & Policies.
The following is required before a student can be scheduled and services can be provided:
*A non-refundable registration fee of $100 (waived for tutoring)
* Registration Form
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