2023 TCG Memorial Academy Summer Experience

Scholar (Student) Name*

First

Last

Date of Birth*

day

/

month

/

year

Parent/Guardian Name #1*

First

Last

Parent/Guardian Name #2

First

Last

Address*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone*

Email*

Any Allergies or Health Concerns? If yes, please specify, as well as any medication or special care required.*

Does your scholar have access to a Chromebook or laptop for use in Technology Curriculum during the program?*

Yes

No

2022-2023 School of Attendance *

2023-2024 School of Attendance*

Parent Name (Electronic Signature) This will serve as your electronic signature confirming your child's participation in our program:*

Today's Date (For Confirmation of Signature)*

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