For students entering 8th and 9th grade in Fall 2008
July 7 - August 1, 2008
8:45 a.m. - 1:30 p.m.
Roxbury High School
$150.00
Participants will receive leadership training &
work as volunteer aides in our Summer Enrichment Courses
Students will develop their:
The Certified Teacher will:
Train students in skills that will help them in their future
employment
Meet with students daily to provide continuous reinforcement of
responsibilities
Observe students in their placements, provide feedback and a
written report
Participation in
this program does not guarantee a paid position for the following year.
ROXBURY COMMUNITY SCHOOL REGISTRATION FORM
I wish to register for the course
listed below.
I have enclosed a check/money order payable to Roxbury Community School or I have included my Visa or MasterCard credit card information and signature below.
Mail to: Roxbury Community School, 1 Bryant Drive, Succasunna, NJ 07876 Fax Number (973) 584-0376
If you have questions, please call (973) 584-7699.
Name: _______________________ Street Address: ____________________Town:_________________Zip:________
Phone (Home): __________________ (Cell): _________________________ (Work): _______________
E-mail: __________________________________________
School: ________________________ Grade in 9/08: _________
Parent/Guardian Name:__________________________________Work/Cell #: ______________________
Parent/Guardian Name:__________________________________Work/Cell #: ______________________
Persons To Be Called if Parent/Guardian in unavailable (Must be completed)
Name: ___________________________ Phone #: ____________________________ Relationship: _______________
Name: ___________________________ Phone #: ____________________________ Relationship: _______________
Child’s Known Medical Conditions (i.e. allergies, asthma, diabetes, seizures): _________________________________
________________________________________________________________________________________________
Treatment/Medication Child is Taking: _________________________________________________________________
Physician’s Name: _________________________________________ Phone #: ______________________________
Special Accommodations needed: _____yes____no
T-Shirt Size: (Please Circle) Youth Large Adult Small Medium Large X-Large XXL
Course Name: Summer Leadership Program Course Tuition: $ 150.00
Visa/MasterCard Number: __________________________________________Exp.Date:______________
Name on Card:__________________________Signature: _______________________________________
No receipt will be given when registering. You may assume your registration has been accepted unless notified.
Participation in Community School activities is at your own risk. The Roxbury Township Board of Education assumes no liability.