Xilin Academy After School Program

2009-2010

1163 E. Ogden Ave., Suite 300-301

Naperville, Illinois 60563

Phone: (630) 355-4322 Fax: (630) 355-4326

REGISTRATION FORM

Student’s Name___________________________________Entering Grade_______________

School______________________________________________________________________

(Name) (Address)

Home Address____________________________________________________________________________

City State Zip

Home Phone_________________________________________________________________

Parent’s Name:

Father ______________________________Work Phone______________________

E-mail Address________________________________________________________

Mother_______________________________Work Phone______________________

E-mail Address_________________________________________________________

Amount of Registration: $125.00 (annually)

Amount Paid: __________________

Balance: ______________________

NOTE: Annual registration fee is non-refundable.