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Application - school year

              AHA! registration – please return to NCES office or Lynn Nania

Student:  _____________________________________  Age: ___________ 

Phone(s): ________________,  __________________, _______________

E-mail address: _______________________________________________

Grade: _______      Teacher: ______________________

Allergies/Medical concerns?: _____________________________________

             ____ full afternoon @ $ 6.00                   =  $___________

             ____ half afternoon @ $ 3.00                  =  $___________  
                       (for homework club or tutoring)

             ____ early dismissal afternoon @$14       = $___________  

Total for all classes                                     =             $____________

        Less 10% for 2nd, 3rd, etc child          -             $____________

Total amount paid at this time                                   $____________

Checks should be made payable to AHA!