Getting

Down in
Puget Sound!

Snohomish School District Registration

presents: deadline:
April 15, 2011
Academy of Arts $499, non-refundable
(scholarships available)
& Sciences 

Limited to 250 students
Shuttle service available
Where learning and fun are ONE! from in-District locations
 Breakfast & lunch included
July 11 - 29, 2011  Certificated teachers
Monday - Friday, 8:45 a.m. - 1 p.m.  Small class sizes

At Emerson Elementary School - 1103 Pine Street Questions? Call

Open to Snohomish students entering grades 1 - 6
 The Snohomish School District School Office
Academy of Arts & Sciences Please date stamp here
2011 Registration Form upon receipt:
Important! The registration deadline is April 15, 2011.
Please attach a check or money order for $99 payable to the Snohomish School District to hold your
place. Return this form and the deposit to your child’s school office. The program is limited to
250 students and preference will be given to earlier registrants. Your deposit will be returned if
enrollment exceeds capacity and we are unable to accommodate your child. The balance ($400)
must be received by June 3, 2011 to complete your registration. Classes will start Monday, July 11 and
run through Friday, July 29.
Additional information, including shuttle pick-up locations, will be sent to you in June.
Questions? Please call Ann Jennings at 360.563.7256.
Student Name: _____________________________________________ Birthday: ______________________
School: _______________________________________ Grade (next fall): ______ Gender: ___________
Parent / Guardian Name(s): ___________________________________________________________________
Address: _____________________________________________ City, ZIP: _____________________________
Email Address: ______________________________________________________________________________
Primary Phone: (_______) _______________________ Alt. Phone: (_______) _______________________

Emergency Contact Information:

Name: _____________________________________________ Relationship to Child: ___________________
Primary Phone: (_______) _______________________ Alt. Phone: (_______) _______________________

Name: _____________________________________________ Relationship to Child: ___________________

Primary Phone: (_______) _______________________ Alt. Phone: (_______) _______________________
Photographs are a natural part of our summer program, and will be a part of the way we communicate and
share experiences at our summer academy. Check the box below only if you do not wish your child to be
photographed.
I do NOT want my student to appear in Snohomish School District photos or videos taken as part of this year’s Summer Academy.
This includes any photos taken by district personnel, family members, community members, teachers and attendees.

- - - - - - - - Teacher / office use only below this line - - - - - - - -

Student Name: _____________________________________________
10-11 Teacher: ________________________________________ Placement: _________________________

Authorizing Signature: _______________________________________

Printed Name: ______________________________________________ Date: ______________________