Summer School Enrollment Form

Which are you enrolling for?

Summer School (June 3rd - July 31st) 8am - 1pmBefore School Care 6:30am - 8am Add +$20 weekAfter School Care 1pm - 3:30pm Add +$20 week
Parent/Guardian #1
Parent/Guardian Full Name*

First NameLast Name
Relationship to Student*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Number*
Work Number
E-mail
example@example.com
Lives with student*

YesNo
Parent/Guardian #2
Parent/Guardian Full Name #2

First NameLast Name
Relationship to Student
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Number
Work Number
E-mail
example@example.com
Lives with student

YesNo

	Select all that apply
□Development Center
□Foster Family home/ Kinship Placement
□Health Institution
□ Hotels/Motels
□ Incarceration Institution
□Temporarily Unsheltered
□ Licensed Children’s Institution
□ State Hospital
□Residential School/ Dormitory
□Temporarily Sheltered
□ Temporarily Doubled Up

	Select all that apply
□Development Center
□Foster Family home/ Kinship Placement
□Health Institution
□ Hotels/Motels
□ Incarceration Institution
□Temporarily Unsheltered
□ Licensed Children’s Institution
□ State Hospital
□Residential School/ Dormitory
□Temporarily Sheltered
□ Temporarily Doubled Up

	Select all that apply
□Development Center
□Foster Family home/ Kinship Placement
□Health Institution
□ Hotels/Motels
□ Incarceration Institution
□Temporarily Unsheltered
□ Licensed Children’s Institution
□ State Hospital
□Residential School/ Dormitory
□Temporarily Sheltered
□ Temporarily Doubled Up

	Select all that apply
□Development Center
□Foster Family home/ Kinship Placement
□Health Institution
□ Hotels/Motels
□ Incarceration Institution
□Temporarily Unsheltered
□ Licensed Children’s Institution
□ State Hospital
□Residential School/ Dormitory
□Temporarily Sheltered
□ Temporarily Doubled Up

	Select all that apply
□Development Center
□Foster Family home/ Kinship Placement
□Health Institution
□ Hotels/Motels
□Temporarily Unsheltered
□ Licensed Children’s Institution
□ State Hospital
□Residential School/ Dormitory
□Temporarily Sheltered
□ Temporarily Doubled Up

Last Question...
Special Education Agreement
Choose one of the Following

Option A: My student has never received Special Education Services of any kind or a 504 Plan. (Example of a special education service is Speech, RSP, Occupational Therapy, ETC.)Option B: My student has an IEP or 504 Plan and I will upload the document and sent to the Enrollment Specialist so a special education team member can contact me and discuss the needs of my student
Please verify that you are human*
Should be Empty:

Summer School