subject_line
Elementary Summer School Registration Form
STUDENT INFORMATION
Student Name
(Last, First, M.I.)
*
Date of Birth
*
+
Student ID #
*
Last Grade
*
K
1
2
3
4
5
Last School
*
CAE
CDN
EHE
ESE
JHE
MCE
MLK
PDS
RRE
SVE
VGE
Student Street Address
*
Student City
*
State
*
🛈
Student Zip
*
Student Phone 1
*
Student Phone 2
Scholarship eligibility
*
Is an English Learner
Is a Native American with a 506 form on file
Has an IEP
Qualifies for the McKinney-Vento program
1st PARENT/GUARDIAN INFORMATION
Parent/Guardian's Full Name
*
Parent/Guardian's Email
*
RRPS Employee?
*
Yes
No
Parent/Guardian Street Address
*
Parent/Guardian City
*
State
*
🛈
Parent Zip
*
Parent/Guardian's Phone 1
*
Parent/Guardian's Phone 2
Parent/Guardian's Phone 3
EMERGENCY INFORMATION
Emergency Contact Name
*
Relationship to Student
*
Emergency Contact Email
*
Emergency Contact Address
*
Emergency Contact Phone 1
*
Emergency Contact Phone 2
Emergency Contact Phone 3
HEALTH & DIETARY INFORMATION
My child has the following health problems (for example: allergy, asthma, seizures, etc.):
Does your child have any dietary restrictions?
(Such as food allergies and/or special diet considerations.)
*
Yes
No
Please list
*
Yes,
Student and Parent agree to the
Parent & Student Agreement
(click to download)
*
Student Signature
*
clear
Student Signature Date
test mode
webmaster only
y
n
Parent/Guardian Signature
*
clear
Parent Signature Date