Burke County High School After-School Title I Program 2015 Student Information & Registration Form

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PURPOSE: The purpose of this program is to provide academic assistance to students who need tutoring, credit, or attendance recovery.

DATES: February 3, 2015 – May 14, 2015 (Tuesdays and Thursdays ONLY)

TIMES: 3:30 – 6:30 P.M.

COST: FREE

MEALS: Snack & Dinner provided

TRANSPORTATION: Provided to all students who attend.

Last Name: *

First Name: *

Middle Initial: *

Cohort: *

Cohort 2015

Cohort 2016

Cohort 2017

Cohort 2018

Home Address: *

City: *

Zip Code: *

Student Cell Phone Number: *

Mother/Guardian's Name: *

Mother's/Guardian's Home Phone Number: *

Mother's/Guardian's Work Phone Number: *

Mother's/Guardian's Cell Phone Number: *

Father/Guardian's Name: *

Father's/Guardian's Home Phone Number *

Father's/Guardian's Work Phone Number *

Father's/Guardian's Cell Phone Number: *

After School Tutorial Assistance (Check all that apply.) *

English-Language Arts

Mathematics

Science

Social Studies

Required

Grade Recovery Assistance (Check all that apply.)

Credit Recovery (PLATO) - Recapturing credit for courses previously failed with a 59 and below. Complete 100% of course based on standards not mastered.

Grade Replacement (PLATO) - Recapturing credit for courses previously failed with a 60-69. Complete 30% of the course based on standards not mastered.

Credit Recovery Course Title:

Grade Replacement Course Title:

Attendance Recovery Assistance

Attendance Recovery – Students who have exceeded the number of days to receive credit in courses.

Please read and respond to the items below that apply to you.

I will need transportation home after attending the Burke County High School After School Title I Program.

I DO NOT need transportation home after attending the Burke County High School After School Title I Program.

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