Excell Program Spring 2021 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 Release of All Claims for Excell Participation is included herewith
Should you have any problems filling out this application, please email,
excel@lacbpe.org
for assistance.
* Required
Email address
*
Your email
Student First Name
*
Your answer
Student Last Name
*
Your answer
Grade Level
*
Choose
2
3
4
5
6
7
8
9
10
11
12
Gender
*
Male
Female
Math Class (Choose One)
*
Choose
2nd Grade Math
3rd Grade Math
4th Grade Math
5th Grade Math
6th Grade Math
7th Grade Math/Pre-Algebra
Algebra 1
Geometry
Algebra II
Trignometry/Pre-Calculus
Calculus
Science Class (Choose One)
*
Choose
2nd Grade Science
3rd Grade Science
4th Grade Science
5th Grade Science
6th Grade Science
General Physical Science
Biology/Life Science
Chemistry
Physics
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.
Yes
No
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
*
This will be used to send Zoom information
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:
*
Choose
$85
$65
Total Number of Students:
*
1
2
3
4
Other:
Date
*
Use the drop down arrow to specify the date that the application was completed
MM
/
DD
/
YYYY
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