PART I: STUDENT INFORMATION Student Name (First, Last) (required) Date of Birth (YYYY-MM-DD) Current School Grade 89101112Other School Name Math Grade (most recent report card) A (80-100%)B (70-79%)C (60-69%)D (50-59%)Not Sure Has the student ever been tested by external agencies (ex. Educational assessments, learning, speech, psychological)? YesNoNot Sure If yes, please explain PART II: PARENT/GUARDIAN INFORMATION Parent/Guardian Name (First, Last) (required) Address (required) Phone Number (required) Your Email (required) PART III: TERMS AND CONDITIONS • REGISTRATION FEE OF $150.00 MUST BE PAID IN ORDER TO REGISTER AND IS NON-REFUNDABLE • CANCELLATIONS MUST BE MADE IN WRITING TO QSLA – Attention: High School Administrator • FEES ARE FULLY REFUNDABLE UP UNTIL 30 DAYS PRIOR TO THE COURSE START DATE. • WITHIN 30 DAYS OF THE COURSE START DATE OR THEREAFTER, NO REFUND WILL BE ISSUED. Δ
PART I: STUDENT INFORMATION
Student Name (First, Last) (required)
Date of Birth (YYYY-MM-DD)
Current School Grade 89101112Other
School Name
Math Grade (most recent report card) A (80-100%)B (70-79%)C (60-69%)D (50-59%)Not Sure
Has the student ever been tested by external agencies (ex. Educational assessments, learning, speech, psychological)? YesNoNot Sure
If yes, please explain
PART II: PARENT/GUARDIAN INFORMATION
Parent/Guardian Name (First, Last) (required)
Address (required)
Phone Number (required)
Your Email (required)
PART III: TERMS AND CONDITIONS
• REGISTRATION FEE OF $150.00 MUST BE PAID IN ORDER TO REGISTER AND IS NON-REFUNDABLE • CANCELLATIONS MUST BE MADE IN WRITING TO QSLA – Attention: High School Administrator • FEES ARE FULLY REFUNDABLE UP UNTIL 30 DAYS PRIOR TO THE COURSE START DATE. • WITHIN 30 DAYS OF THE COURSE START DATE OR THEREAFTER, NO REFUND WILL BE ISSUED.
Δ
