STEP UP TO STAPLEY
7TH Grade Summer Program Application
Due ASAP on a First Come First Serve Basis
Student’s Name: ______________________________________________________________________
Address:
______________________________________________________________
_____________________________________________________________
_____________________________________________________________
Parent/Guardian Name:
_______________________________________________________________
Parent/Guardian Signature: ______________________________________________________________
Home Phone:
_______________________________________________________________
Cell Phone:
_______________________________________________________________
Work Phone:
_______________________________________________________________
E-mail :
_______________________________________________________________
EMERGENCY CONTACT:
Name: ___________________________________________ Phone: ____________________________________
Please check if any of the following will apply:
____ I will be providing transportation for my student
____ My student will ride a bike or walk to the program
____ My student will be attending all 10 days of the program
____ My student will only be attending on the following dates:
__________________________________________________________________________
If anyone other than the parent/guardian will be providing transportation for the student, please provide
his/her name and cell number:
Name_________________________________________________ Phone: _______________________
Name:
Applications may be returned via fax, mail, or dropped off at the front office.
Stapley Junior High School
3250 E. Hermosa Vista
________________________________________Phone:___________________________
Mesa, AZ 85213
Fax: 480-472-2828