LuHi Summer Programs Registration 2016 LuHi Summer
LuHi Summer Programs Registration 2016 131 Brookville Road, NY 11545 • Phone: 516-626-1100 • Fax: 516-626-0694 STUDENT'S NAME LAST
FIRST
CITY
ADDRESS M
GRADE (as of 9/15)
D.O.B
AGE
MOTHERS NAME FATHERS NAME
ST
ZIP
HOME PHONE
WORK PHONE
CELL
WORK PHONE
CELL
BILLING ADDRESS
E-MAIL ADDRESS
By enrollment in our programs, permission is granted to use any photograph in connection with publicity for LuHi Summer Programs. Permission is also granted to take participants off campus for field trips or rainy day activities without additional parental permission for each occurrence. Enrollment in LuHi Summer Programs establishes permission for child to engage in all program activities except as noted by the examining physician on child's signed Health Certificate, which must be on file in our Health Office prior to the start of any program. In the event of an emergency, permission is granted for first aid and/or proper treatment to be administered to child as determined by the registered nurse on staff. There is NO REFUND after April 15'*' for cancellation before the program begins or withdrawal during a session once the session has begun FOR ANY REASON (including illness, injury, personal, act of God, etc.). See LuHi.org for information on Tuition Insurance.
LUNCH PROGRAM PARENT/GUARDIAN'S SIGNATURE
FOR CREDIT CARD USE (VISA/MASTERCARD/AMERICAN EXPRESS) PLEASE FILL OUT AND SIGN AIVlEX-4 small #'s on front VISA/MC 3 small #'s on back
CARD VERIFICATION #
NAME ON CARD
EXPIRATION DATE
CREDIT CARD #
AMOUNT Minimum deposit of $250.00 per session with application; Full tuition after June 15th
SIGNATURE Cardholder agrees to perform the obligation set forth in the Cardholder's agreement with issuer.
LuHi Summer Programs
TRANSPORTATION 2016
DO NOT DETACH
STUDENT'S NAME LAST
FIRST
TRANSPORTATION ADDRESS
NEAREST INTERSECTION STREET
TOWN
PARENT/GUARDIAN CONTACT DAY
HOME PHONE
EVE
Check here if transportation address is different than Student's address PROGRAM
TRANSPO ID
OlS
THIS SECTION IS FOR
SESSION 1
OFFICE SESSION USE SESSION ONLY! SESSION
II III IV (PLEASE TURN OVER AND FILL OUT OTHER SIDE)
PROGRAM
LuHi Summer Programs is permitted to operate by the Nassau twice yearly with reports filed at: 200 Country Seat Dr. Mineol
Program in Session Program NOT in Session
$100 "Please Note: Discounts will be forfeited if accounts are not pa June 15th must be paid in full to be eligible for discounts. DISC will be adjusted if any scheduling changes are made.
Sibling Discount:
Note discounted amount will be deducted from the last session a
Multi-Session: 2 Sessions, Same Student: $200 3 Sessions, Same Student: $450 4 Sessions, Same Student: $700
Summer 2016 - Disco
registrations. Note: Students registered before 6/15/ 6/15/16 at the regular price.
Registrations After 6/15/16 - There will be a
program.
Early Bird - All registrations received before 3/1
Important Pricing In
Sunday, January 24*1^ 1 Sunday, March 13*^ 1 Sunday, April 24**' 1
Summer 2016 - Open
Get Program/General Inf Answers to Frequently Asked Download Forms & Appl Join our E-Mail Notificatio
www.luhisumme
Save Time & Paper - Regi
Summer Progr
Lu
APPIICATION KEY
There is a $25 fee to change a program after June 16"'
The white boxes following each program correspond to the dates for which the program is offered. Please mark accurately in the box to indicate the sessionis) you plan to attend. You may only enroll in ONE PROGRAM PER SESSION.
Please make ail checks payable to Lutheran High School Association
This deposit is NONREFUNDABLE after April 15th, 2016.
A $250 deposit for each session enrolled must accompany this application.
LuHi Summer Programs 131 Brookville Road Brookville, NY 11545
Please complete both sides of this form and return to LuHi at the following address:
IMPORTANT PLEASE READI
Session 1: 6/27 - 7/8 Session!: 7111-1111 Session 3: 7/25 - 8/5 Session 4: S/8-8/19
FIRST
CITY
ADDRESS M
GRADE (as of 9/15)
D.O.B
AGE
MOTHERS NAME FATHERS NAME
ST
ZIP
HOME PHONE
WORK PHONE
CELL
WORK PHONE
CELL
BILLING ADDRESS
E-MAIL ADDRESS
By enrollment in our programs, permission is granted to use any photograph in connection with publicity for LuHi Summer Programs. Permission is also granted to take participants off campus for field trips or rainy day activities without additional parental permission for each occurrence. Enrollment in LuHi Summer Programs establishes permission for child to engage in all program activities except as noted by the examining physician on child's signed Health Certificate, which must be on file in our Health Office prior to the start of any program. In the event of an emergency, permission is granted for first aid and/or proper treatment to be administered to child as determined by the registered nurse on staff. There is NO REFUND after April 15'*' for cancellation before the program begins or withdrawal during a session once the session has begun FOR ANY REASON (including illness, injury, personal, act of God, etc.). See LuHi.org for information on Tuition Insurance.
LUNCH PROGRAM PARENT/GUARDIAN'S SIGNATURE
FOR CREDIT CARD USE (VISA/MASTERCARD/AMERICAN EXPRESS) PLEASE FILL OUT AND SIGN AIVlEX-4 small #'s on front VISA/MC 3 small #'s on back
CARD VERIFICATION #
NAME ON CARD
EXPIRATION DATE
CREDIT CARD #
AMOUNT Minimum deposit of $250.00 per session with application; Full tuition after June 15th
SIGNATURE Cardholder agrees to perform the obligation set forth in the Cardholder's agreement with issuer.
LuHi Summer Programs
TRANSPORTATION 2016
DO NOT DETACH
STUDENT'S NAME LAST
FIRST
TRANSPORTATION ADDRESS
NEAREST INTERSECTION STREET
TOWN
PARENT/GUARDIAN CONTACT DAY
HOME PHONE
EVE
Check here if transportation address is different than Student's address PROGRAM
TRANSPO ID
OlS
THIS SECTION IS FOR
SESSION 1
OFFICE SESSION USE SESSION ONLY! SESSION
II III IV (PLEASE TURN OVER AND FILL OUT OTHER SIDE)
PROGRAM
LuHi Summer Programs is permitted to operate by the Nassau twice yearly with reports filed at: 200 Country Seat Dr. Mineol
Program in Session Program NOT in Session
$100 "Please Note: Discounts will be forfeited if accounts are not pa June 15th must be paid in full to be eligible for discounts. DISC will be adjusted if any scheduling changes are made.
Sibling Discount:
Note discounted amount will be deducted from the last session a
Multi-Session: 2 Sessions, Same Student: $200 3 Sessions, Same Student: $450 4 Sessions, Same Student: $700
Summer 2016 - Disco
registrations. Note: Students registered before 6/15/ 6/15/16 at the regular price.
Registrations After 6/15/16 - There will be a
program.
Early Bird - All registrations received before 3/1
Important Pricing In
Sunday, January 24*1^ 1 Sunday, March 13*^ 1 Sunday, April 24**' 1
Summer 2016 - Open
Get Program/General Inf Answers to Frequently Asked Download Forms & Appl Join our E-Mail Notificatio
www.luhisumme
Save Time & Paper - Regi
Summer Progr
Lu
APPIICATION KEY
There is a $25 fee to change a program after June 16"'
The white boxes following each program correspond to the dates for which the program is offered. Please mark accurately in the box to indicate the sessionis) you plan to attend. You may only enroll in ONE PROGRAM PER SESSION.
Please make ail checks payable to Lutheran High School Association
This deposit is NONREFUNDABLE after April 15th, 2016.
A $250 deposit for each session enrolled must accompany this application.
LuHi Summer Programs 131 Brookville Road Brookville, NY 11545
Please complete both sides of this form and return to LuHi at the following address:
IMPORTANT PLEASE READI
Session 1: 6/27 - 7/8 Session!: 7111-1111 Session 3: 7/25 - 8/5 Session 4: S/8-8/19
