Entering 5th Grade - Title I Summer School Jumpstart Program
Students who participate in the program will receive instruction emphasizing social and emotional development, cross-curricular learning in math and reading, as well as problem solving and critical thinking skills.

This program will be held from MONDAY - FRIDAY 8:15 AM - 12:45 PM

This program will begin on MONDAY JULY 8, 2019, and run through FRIDAY AUGUST 2, 2019

All children will be ready for dismissal promptly at 12:45 PM in the upper playground of the school.

Student Name: *
If you have more than one child, please complete a separate form for each child participating.
Your answer
*
Will your child be joining us for this year's summer program?
For students who walk home:
Emergency Contact Information
Parent (or Legal Guardian) Name: *
Parent 1 (ex. Mother)
Your answer
Parent (or Legal Guardian) Cell Phone Number: *
Parent 1 (ex. Mother)
Your answer
Parent (or Legal Guardian) Name:
Parent 2 (ex. Father)
Your answer
Parent (or Legal Guardian) Cell Phone Number:
Parent 2 (ex. Father)
Your answer
Email Address:
Your answer
Home Address: *
Your answer
Home Phone Number: *
Your answer
#1 Emergency Contact Name & Relationship: *
The name & relationship of your emergency contact can be listed here. (ex. Jane Doe-Aunt)
Your answer
#1 Emergency Contact Number: *
The name & relationship of your emergency contact can be listed here. (ex. Jill Doe-Cousin)
Your answer
#2 Emergency Contact Name & Relationship:
Your answer
#2 Emergency Contact Number:
Your answer
Additional People to whom my child(ren) may be released:
Please enter Name, Relationship and Phone Number of additional people to whom your child may be released. You may list up to 2 additional people. (ex. Jane Doe-Aunt-1234567890, Jill Doe-Cousin-1234567890)
Your answer
Parent Signature *
Please sign, initial and date form before submitting. (Ex. John Doe J.D. 6/21/19)
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Township of Union Schools. Report Abuse - Terms of Service