Round Lake Campus
Youth Registration Form
STUDENT INFORMATION Child Name: ____________________________________
Gender: Male / Female / Prefer not to answer
Nickname:______________________________________
Current grade: ______________________
Age: ____
Program Title: ___________________________________
Date of Birth (mm/dd/yy): _______________
Program Dates: __________________________________
PARENT / GUARDIAN INFORMATION ______________________________________________ Parent / Guardian 1: Name ______________________________________________ Relationship to child ______________________________________________ Address City/State/Zip ___________________________________________ Home phone Work phone ______________________________________________ Cell Preferred email _____________________________________________ Business name Occupation _____________________________________________ Business address Parents are
* married
* separated
______________________________________________ OPTIONAL Parent / Guardian 2: Name ______________________________________________ Relationship to child ______________________________________________ Address (if different) City/State/Zip ______________________________________________ Home phone Work phone ______________________________________________ Cell Preferred email ______________________________________________ Business name Occupation ______________________________________________ Business address
* divorced
* widowed
* single
* foster
TUITION AGREEMENT After receiving your registration form, the tuition agreement is complete with a signature from North Country School. I have read the TUITION PAYMENT POLICY and agree to the payment and penalty terms. I understand all billing will be via email and sent to the address listed below. Please indicate your payment installment frequency: One / Two Please initial (________) and date (____ / ____ / ____). PARENT/GUARDIAN 1 SIGNATURE:
Date:
NORTH COUNTRY SCHOOL SIGNATURE:
Date:
ROUNDLAKECAMPUS.COM I 4382 CASCADE RD. I LAKE PLACID, NY 12946 I (518) 523-9329 E XT. 5440