De La Salle Enrollment Form for Hybrid Bio Course Student Information: First Name____________________________ Last name ____________________________ Current grade level at DLS __________________________ Student E-mail (Please use your DLS e-mail) _____________________ Student Phone Number _____________________ Semester for remediation: (Please circle) Semester 1 Semester 2
Full Course
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 18th). Payment Method: VISA /MasterCard
Check
Cash
Name on Card _______________________________________ Address ________________________________________________ Telephone number ________________________________________ Account Number on Card _______________________________________________________ Expiration Date ______ Amount _______