De La Salle Enrollment Form for Hybrid Course First Name__________________
Last name ____________________________
Current grade level at DLS __________________________ Student E-mail (Please use your DLS e-mail) _____________________ Student Phone Number _____________________ Subject for remediation: _____________________________________ Semester for remediation: (Please circle) Semester 1 Semester Parent/Guardian Name _________________________________ Parent/Guardian Phone _________________________________ Parent/Guardian E-mail __________________________________ Payment Information: Please select a payment method below. Checks should be made payable to De La Salle High School and delivered to Mr. Van Bomel. $300 is due at time of enrollment and the remaining payment is due before the start of the course (June 11th). Payment Method: VISA /MasterCard
Check
Cash
Name on Card _______________________________________ Address ________________________________________________ Telephone number ________________________________________ Account Number on Card _______________________________________________________ Expiration Date ______ Amount _______