Please print this form and mail with a check to hold your spot. Spaces are limited.

Student's Name:____________________________________________
Student's Age and Grade:_____________________________________
Student's Email (optional): _____________________________________
Parent's Name: _____________________________________________
Parent's Email:______________________________________________
Parent's home phone: ________________________________________
Parent's cell phone: __________________________________________
Emergency contact number: ___________________________________

Does your child have any issues (learning or otherwise) we should know about? (Feel free to continue on the back of the form.)

 

Does your child have any allergies we should know about? (Feel free to continue on the back of the form.)

 




We are registering for:

______ Saturday, January 14 9 AM - 2 PM, High School class $375 (Early Bird Special: $325 before January 1, 2017)

______ Saturday, January 14 2:20 PM - 3:20 PM, College Essay lecture (free if your child is registered for High School Class above. Otherwise $10)

_____ Sunday, January 15 9 AM - 1 PM, Middle School Class $300 (Early Bird Special: $250 before January 1, 2017)


Please make your check out to "Education in Action" and mail it to:
Shari Becker
29 Addington Rd.
Brookline, MA 02445