Wufoo
Summer Literacy Intervention Program
at California State University, Northridge
Summer 2009
Parent's Name
First
Last
Student's Name
First
Last
Student's Grade Level in Fall 2009
Home Phone Number
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Cell Phone Number
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Email
Session Selection: Please indicate if you want to enroll for two days per week (MW or TTH) or four days per week.
Two Days (Monday, Wednesday)
Two Days (Tuesday, Thursday)
Four Days (M-Th)
Please indicate first, second, third, and fourth choices for session times.
First Choice
Second Choice
Third Choice
1:30-2:30
1
2
3
2:30-3:30
1
2
3
3:30-4:30
1
2
3
Please indicate if your child is deaf or hard of hearing.
Additional Comments or Notes:
Do Not Fill This Out
