All payments must be received by MONDAY, FEBRUARY 1ST or your child's name will be removed the roster.
Winter Enrichment Class Payment Remittance
You must submit this page with payment for all classes for which you registered via the sign up links.
Only 1 form per family is necessary
Contact information to be used by program instructors:
Email address:____________________________________________________________________
Phone number:___________________________________________________________________
Student Name:____________________________________________________________________
Grade: _____________ Teacher’s Name: _______________________________________________
WE classes registered for:
__________________________ __________________________ __________________________
Student Name:____________________________________________________________________
Grade: _____________ Teacher’s Name: _______________________________________________
WE classes registered for:
__________________________ __________________________ __________________________
Student Name:____________________________________________________________________
Grade: _____________ Teacher’s Name: _______________________________________________
WE classes registered for:
__________________________ __________________________ __________________________
If you need to add more space please print another sheet or use the back of this one.
Cash:_______ Check #:______________ (make checks payable to DHSA, you need only submit 1 check per family)
Total Amount Submitted:_______________
You must submit this page with payment for all classes for which you registered via the sign up links.
Only 1 form per family is necessary
Contact information to be used by program instructors:
Email address:____________________________________________________________________
Phone number:___________________________________________________________________
Student Name:____________________________________________________________________
Grade: _____________ Teacher’s Name: _______________________________________________
WE classes registered for:
__________________________ __________________________ __________________________
Student Name:____________________________________________________________________
Grade: _____________ Teacher’s Name: _______________________________________________
WE classes registered for:
__________________________ __________________________ __________________________
Student Name:____________________________________________________________________
Grade: _____________ Teacher’s Name: _______________________________________________
WE classes registered for:
__________________________ __________________________ __________________________
If you need to add more space please print another sheet or use the back of this one.
Cash:_______ Check #:______________ (make checks payable to DHSA, you need only submit 1 check per family)
Total Amount Submitted:_______________