8^th Grade Study Club

Application

(an interview will be scheduled upon receipt of the application)

Name: _________________________________________ Date of Birth: ____________

Avg. Math Grade: _________ Avg. English Grade: _________ Avg. Grade: ___________

School Now Attending: ________________________

High School(s) Applying to: _______________________

Parent’s Information: (Please fill in whatever is applicable.) Email: ________________________

Name of Father: _______________________________ Work Phone Number: ____________________

Name of Mother: ______________________________ Work Phone Number: ____________________

Father’s Occupation: _______________________ Mother’s Occupation: __________________________

Home Address: __________________________________ Home Phone Number: _________________

City: _______________________________ State: _____________ Zip Code: ___________________

How did you hear about 8^th Grade Study Club?: _____________________________________________________________

N.B. The Directors of 8^th Grade Study Club reserve the right to dismiss any student who is uncooperative and disruptive to the Club’s overall program.

Payment ($100) due first day of Class. Write check payable to Chaucer Drive Study Center.

Send application to:

jlm@chaucercenter.net

OR

Fax it to 713- 523-4169

OR

8^th Grade Study Club

Chaucer Drive Study Center

5505 Chaucer Drive

Houston, TX 77005-2631

(713) 523 4351 x 233

For more information, log onto www.chaucercenter.net