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2023 Elementary Extended School Year Registration/Medical Form
Complete and submit this form prior to enrolling your child in our Elementary Extended School Year program. Complete one form for each child being enrolled.
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* Indicates required question
Student's Last Name
*
Your answer
Student's First Name
*
Your answer
Student's Current Grade (2022-2023 School Year)
*
Your answer
Student's Current School
*
Bethlehem
Elm Grove
Madison
Middle Creek
Ritchie
Steenrod
Warwood
West Liberty
Woodsdale
Student's Homeroom Teacher
*
Your answer
Parent/Guardian Name
*
Your answer
Parent/Guardian Current Email
Your answer
Current Street Address
*
Your answer
Phone Number
*
Your answer
Alternate Phone Number
*
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Phone Number
*
Your answer
Allergies/Medical Notes
*
Your answer
Special Needs
*
Your answer
Week(s) that your child will attend the Extended School Year program. (Check all that apply.)
*
Week 1-Monday, June 26-Friday, June 30, 2023
Week 2-Monday, July 3-Friday, July 7, 2023 (No session on Tuesday, July 4)
Week 3-Monday, July 10-Friday, July 14, 2023
Week 4-Monday, July 17-Friday, July 21, 2023
Required
Transportation
*
My child will ride the bus.
My child will be a car rider.
Please list the name and phone number of those permitted to pick up your child. (These people will be required to show identification.)
Your answer
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