Student's Name	____________________________________

Address	____________________________________________

	____________________________________________

City	____________________________  State ____  Zip ______

Parent's Telephone _________________________________________

Parent's email address _____________________________________

Student's Telephone ________________________________________

Student's email address ____________________________________

Grade completed as of June 2010 _______________________

Present School  _______________________________________

School as of next year __________________________________

Please register me for the Envi-Sci Program. I have enclosed
a check for the following (please check all that apply):
[ ] Deposit of $150.  I agree to pay the balance by May 1, 2010.
    If we receive deposit by Jan. 31st, tuition will be reduced by $50.
[ ] Before January 31st, Early Bird Tuition of $1,045.
[ ] After January 31st, Regular Tuition Fee of $1,095.
[ ] I would like to make a tax-deductible contribution
    to the Envi-Sci Scholarship Fund of $________

Total amount enclosed $________
Make checks payable to:
Environmental Science Program, City of Newton

Partial scholarships may be available, based on need. To request
a scholarship, contact David Backer at 617-969-0288, 9-5, M-F.


__________________________________________________
Name of Parent or Guardian (printed)


_______________________________________
Signature of Parent or Guardian

How did you hear about the Program? __________________________