ABBA Educational Consultants   

Summer Academic Academy Registration Form

 Mail Registration: Return completed form with $90 check or money order to
                           ABBA Educational Consultants, P.O. Box 1671, Bowie MD., 20717-1671

Online Registration: 1) E-mail completed form to learn@abbaed.com  2) Pay at www.abbaled.com/payment

   Date: _________________                                                      

Family Information 

Your name:                                                       

Relationship to student:

Telephone Numbers
Home:                        Work _______________
Cell:                           Other: _____________ ___

E-mail  Address (required):                                                                            

Your address:  
                        __________________                       __________________     

Student Information 

Student name:
Student: Grade:                                                     
Student Age:                            
Student Birth date: _________

Student address  (if different from yours) 
_____________________    _____________________ 

 Emergency contact info. (other than you)
        ___________________________         ___________________________ 

 

 

School/Grade Information

Student’s School:                                                            
Has student been diagnosed with a learning disability, ADD, ADHD, other?                              

§           If yes, is student on medication for above?                               

Did student receive at least one progress report in math this year? _____   Last report card grade in math      
Did student receive at least one progress report in reading this year?  ___  Last report card grade in reading    

**If student is in high school, indicate HAS tests completed: English _ Math  Biology _ Soc. Studies

 - - - - - - - - - - - - - - - - - - - - - - - - - - To be completed after June 30th, 2006 - - - - - - - - - - - - - - - - - - - - - - - -

Student Math Grade:                                                                      Student 2006 Math MSA/HSA Score:      Students Reading / English Grade:                                                Student 2006 Reading MSA/HSA Score:     

 General Information

 §           What would you like your child to be able to do as a result of attending this program
that he or she is not doing now? _______________________________________________________________________________________________
_______________________________________________________________________________________________

 §           Do you have any learning concerns about your child? If yes, please explain.________________________________________________________________________________________
_______________________________________________________________________________________________