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Corporate Office 3075 Clairton Road Suite 930 West Mifflin, PA 15123 Phone: 412.650.9004 Fax: 412.650.0304

MIDDLE AND HIGH SCHOOL SUMMER SCHOOL 2012 REGISTRATION FORM PHASE 4 Learning Center will conduct Summer School for Middle and High School students at our Century III Mall location Wednesday June 20th thru Wednesday July 11th, with Wednesday July 4th being an observed holiday for all students and staff. Morning session will run 8:00am12:00pm and the afternoon session will run 12:00pm-4:00pm. Registration for summer school must be made in person at the Center Century III Mall location. Registration fees will be accepted starting immediately between 8:00AM and 4:00PM, and including the start of session on Wednesday June 20th. Classes will be filled on a first come first serve basis. You must bring this form with your counselor and parent’s signatures and full payment for courses to be taken. Tuition for summer courses is $200/course. Non-refundable payment may be made in the form of cash, or money order made payable to “PHASE 4 Learning Center”. Students taking two courses must attend both morning and afternoon sessions five days a week. Student and parent signatures indicate that the student agrees to be in attendance for all sessions during summer school and that the student will comply with school and site rules. Registration requires that the school counselor sign this form. Please PRINT the following information: Student’s Name:

School District:

Street Address:




Home Phone:

Cell Phone:

Zip Code:

Parent/Guardian Name: Course(s) Needed: School Counselor’s Signature:


School Counselor’s Phone Number w/Extension _____________________________________ Student’s Signature:


Parent’s Signature: