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Pleasant Hill R-III School District Summer School

Due Friday April 30th

Pre-K thru 6th Registration Form

For Office Use Only

P

E

I

Name

____________________________________________________________________

(First)

(Middle Initial)

(Last)

Birth Date _____________________

Age __________

Gender

________

Grade level for 2009-2010

_____________

Parent/Guardian

________________________________________________________________

Address _____________________________City __________________

Sta

te

_______

Zip _________

Home Phone _____________________Work Phone

_________________________

Emergency Contact Person

_______________________________________________

Phone ____________________________

Will your student need bus transportation? (circle one)

YES

NO

List the classes for which you wish to register. List in order your top 4 choices.

Every effort will be made to place students in their top 2 choices.

Please remember class availability is subject to student enrollment.

1) Course Name

____________________________________________

2) Course Name

____________________________________________

3) Course Name

____________________________________________

4) Course Name ____________________________________________

I have read the summer school information. I agree to follow all Pleasant Hill R-3 policies and procedures. I further understand that I will be asked to leave Summer School if I choose not to follow these policies and procedures.

Student Signature

______________________________________

Parent Signature

_______________________________________

PLEASE RETURN TO YOUR CHILD’S SCHOOL OR TO PLEASANT HILL MIDDLE SCHOOL ATTENTION: KAREN TARPENNING 1301 MYRTLE

For Office Use Only SIS enrollment

_____________________

PLEASANT HILL, MO 64080.

Fax 816-987-2017 TH BY FRIDAY, APRIL 30

Date Received

___________________

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