DICE :: Detroit Indian Center

Summer Program 2019 Enrollment Form

Please complete the form below and submit along with an initail deposit of $350. This initial deposit will be later applied towards the payment for the enrolled weeks. You will receive a confirmation email after your succesful enrollment along with the payment.

Make sure that you have read our Summer Program policies, requirements, pricing and general information. Sibling discount (if applicable) will be applied at the time of remaining balance payment. Thank you. Call us at (248) 962-3678 for more information or if you have any questions.

STUDENT INFORMATION

*First Name:

*Last Name:

*Date of Birth:

mm/dd/yyyy

* Gender

Male Female

*Grade Completed:

PARENT/GUARDIAN INFORMATION

*Father's Name:

*Father's Phone:

*Mother's Name:

*Mother's Phone:

* Primary Email:

Alternate Email:

* Address:

* City:

* State:

* Zip Code:

EMERGENCY CONTACT INFORMATION

*1st Contact Name:

*1st Contact Phone:

*2nd Contact Name:

*2nd Contact Phone:

Days/Weeks Interested

You must select a minimum of 3 weeks with atleast 3 days in each of those weeks.

June 16 Select All Clear All	Mon 06/17 Enroll	Tue 06/18 Enroll	Wed 06/19 Enroll	Thu 06/20 Enroll	Fri 06/21 Enroll	Total N/A
June 23 Select All Clear All	Mon 06/24 Enroll	Tue 06/25 Enroll	Wed 06/26 Enroll	Thu 06/27 Enroll	Fri 06/28 Enroll	Total N/A
Jun 30 Select All Clear All	Mon 07/01 Enroll	Tue 07/02 Enroll	Wed 07/03 Enroll	Thu 07/04 Holiday	Fri 07/05 Enroll	Total N/A
July 07 Select All Clear All	Mon 07/08 Enroll	Tue 07/09 Enroll	Wed 07/10 Enroll	Thu 07/11 Enroll	Fri 07/12 Enroll	Total N/A
July 14 Select All Clear All	Mon 07/15 Enroll	Tue 07/16 Enroll	Wed 07/17 Enroll	Thu 07/18 Enroll	Fri 07/19 Enroll	Total N/A
July 21 Select All Clear All	Mon 07/22 Enroll	Tue 07/23 Enroll	Wed 07/24 Enroll	Thu 07/25 Enroll	Fri 07/26 Enroll	Total N/A
July 28 Select All Clear All	Mon 07/29 Enroll	Tue 07/30 Enroll	Wed 07/31 Enroll	Thu 08/01 Enroll	Fri 08/02 Enroll	Total N/A
August 04 Select All Clear All	Mon 08/05 Enroll	Tue 08/06 Enroll	Wed 08/07 Enroll	Thu 08/08 Enroll	Fri 08/09 Enroll	Total N/A
August 11 Select All Clear All	Mon 08/12 Enroll	Tue 08/13 Enroll	Wed 08/14 Enroll	Thu 08/15 Enroll	Fri 08/16 Enroll	Total N/A
August 18 Select All Clear All	Mon 08/19 Enroll	Tue 08/20 Enroll	Wed 08/21 Enroll	Thu 08/22 Enroll	Fri 08/23 Enroll	Total N/A
August 25 Select All Clear All	Mon 08/26 Enroll	Tue 08/27 Enroll	Wed 08/28 Enroll	Thu 08/29 Enroll	Fri 08/30 Enroll	Total N/A

Please click the button below to enroll and make an initial deposit of $350.
This deposit will be applied towards your payment for enrolled weeks later.

By clicking the 'Submit Enrollment' button above, you agree to our Terms and that you have read our Summer Program Enrollment Policies.