Parent and Student Information: Please fill out all fields so we can match your payment with your records in our office! Parent's First Name:   Student's First Name: Parent's Last Name:   Student's Last Name: Address:   Student's Birth Date: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 City:   Grade Level (upcoming): 0 1 2 3 4 5 6 7 8 9 10 11 12 State: DC MD VA PA WV Zip code:   Gender: Male Female         Telephone: (home)   E-mail:   (work)       (cellular)               Please Specify the Purpose of Your Payment: To make sure your payment is applied towards the correct account, please note the reason for your payment. Program Type: Invoice Type: Invoice Month: Invoice Year: Select Program Type... Tutoring After School Mentoring Other Select Type of Payment... Current Invoice Past Due Invoice Select Month... January February March April May June July August September October November December Select Year... 2005 2006 2007 Notes: Please note any special circumstances here: Note special circumstances here. Amount for Payment: Enter amount of payment in the box below. The amount of your payment will be: $ .

The Enrichment Centers has a 'NO REFUND' policy for all of our summer programs. When registering, please be sure that your child is able to attend the program.