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Lasker Math Success Academy Student Enrollment Application

Parent/Guardian Information

Parent First Name*

Parent Last Name*

Email Address*

Phone Number*

Student Information

Student Full Name*

Student Date of Birth*

Month

Day

Year

Student Grade Level*

Current School Name*

Program Selection

Enrollment Program*

After-School Program

Summer Camp

Weekend Workshops

One-on-One Tutoring

Preferred Start Date*

Math Goals and Learning Needs

Emergency Contact

Emergency Contact Name*

Emergency Contact Phone*

Authorization

I hereby certify that the information provided is accurate and I agree to the Academy Terms and Conditions.

Parent/Guardian Signature*

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