US & INTERNATIONAL K—8 PROGRAM E-TAP SPECIAL
______________________ ______________________
Father's (Guardian's ) Last Name First Name
______________________ ______________________
Mother's (Guardian's ) Last Name First Name
______________________ ______________________ _______ _______
Street Address City State Postal Code
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Nation Phone (the one consultants will Email
call you on)
| Last | First | Middle | Sex | Birth Date | Grade | Fee |
|---|---|---|---|---|---|---|
| $ 525 | ||||||
| $75 | ||||||
| $75 | ||||||
| $75 | ||||||
| Total amount due at enrollment - add all fees that apply: | $ | |||||
| Name on Card | Account # (e.g. 4515-8547 etc) | Expires (e.g. 04/10) |
(If you do not feel comfortable emailing card information, you can phone it in: 410-730-0073)
STATEMENT OF PARENTAL RESPONSIBILITY
We the parents/guardians understand that we hold full responsibility for the education of our children.
Typing your name is electronic signature
| Mother | Father | Date |
Checks payable to: TLCI. Mail: Office of Principal Director 9085 Flamepool Way Columbia, MD 21045
To email forms: MSmith@tlci.us