HORIZON
MID-WINTER INTERSESSION REGISTRATION 2012
Space
Exploration! February 13 -24, 2012
Child’s Name _______________________________________ Grade ______________ Teacher ____________________
Parent’s Name _______________________Home Phone _____________ Work Phone (Mom) ______________ (Dad) __________
Home Address _____________________________ City __________________________ Zip Code _____________________
After school my child will: _____ walk home OR _____ be picked up by ___________________OR _____ attend child care
Does your child have any allergies? Special needs? Please describe below.
My child is taking the following medication
_____________________________ and requires it at the following
time(s): ___________
Payment: $100.00
for the week of February 13 - 17, 2012
With check # __________Please make check payable to: Holt Public Schoo1
Payment: $100.00
for the week of February 20-24, 2012
With check # __________Please make check payable to: Holt Public Schools
If paying by credit card, please
put card type and numbers down even if they are on file at Community Ed.
This goes through a separate account and won’t allow
access to your information on file.
REGISTRATION FORM MUST BE TURNED IN TO YOUR
CHILD’S CLASSROOM TEACHER, THE HORIZON OFFICE, OR HORIZON CHILD
CARE no later than Wednesday, February 1, 2012
***All LATE
registrations will be charged a $15.00/per week late fee. ** |
Visa/MasterCard # ____________________________ Expiration Date ____________ Signature on card________________________
Your child will receive field trip and special event information on their first day of Intersession.