JPS Title I Summer School Registration Form
Please fill in all requested information below for the student being enrolled in summer school.
Email address *
Part 1: Student Information
Last name *
First name. *
Address (Street, City, State, Zip code) *
Date of birth: *
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Home Phone *
Students School *
Students Grade Level *
Gender *
Major medical conditions and medications: *
NA *
Race *
Educational Program *
Transportation *
Insurance Coverage *
Do you have wifi (internet) in your home? *
Part 2: Parent/Guardian #1 Information
First and last name. *
Address (street, city, state, zipcode) *
Work phone number *
Cell or home phone number *
Parent's email address *
Parent's primary language *
Marital status *
Relationship to child *
Do you live with the student? *
Employer and hours *
Parent/Guardian #2 Information
First and last name *
Address (street, city, state, zipcode) *
Work phone number *
Cell or home phone number *
Parent's primary language *
Parent's email address *
Marital status *
Relationship to child *
Do you live with the student? *
Employer and hours. *
Part 3: Emergency Contact Information
First and last name *
Address (street, city, state, zipcode) *
Home or cell phone number *
Work phone number *
Email address *
Relationship to student *
Authorized to pick up student? *
Part 4: Adult authorized to pick up student
First and last name *
Address (street, city, state, zipcode) *
Email address *
Home or cell phone number *
Work phone number *
Relationship to student *
Part 5: Permissions
Check all appropriate *
Required
If your child is riding the bus please read and check appropriate boxes *
Required
Parent electronic signature
Today's date
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Submit
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