On-Site E-Learning Registration

Thank you so much for your interest in the Stone CDC On-Site E-Learning Center! Please complete the registration form as accurately as possible. Please note that our On-site E-learning Center is for students in grades K-6 and will operate from 9 AM-2:30 PM.

First Name *

Last Name *

Street Address *

City *

State *

Zip *

Phone *

Email *

Please list your child's name, grade, school (Ex. John Mitchell, 6th, Disney School) If you have multiple children, please enter additional children separately in the next question. *

Additional Children: Please list your child's name, grade, school (Ex. John Mitchell, 6th, Disney School)

Child(ren) Birthdate's (Format: xx/xx/xxxx) *

What challenges are you experiencing with e-learning? *

Limited or No Access to Internet

Limited or No Technology (Ipad, Laptop, Desktop, etc)

Lack of space/quiet space

Lack of Motivation/Self- Management

Required

Please select the choice that describes your child's reading skills. *

My child struggles with reading but is on track.

My child has no issues with reading (for their grade level)

My child struggles with reading and needs a tutor/academic support.

My child is a Diverse Learner/IEP

Other:

Required

Please select the choice that best describes your child's math skills. *

My child struggles with math but is on track.

My child has no issues with math (for their grade level).

My child struggles with math and needs a tutor/academic support

My child is a Diverse Learner/IEP

Other:

Required

Please provide your child(ren)'s school':s e-learning time schedule. List their lunchtime. Ex. 8:30A-2:30P, Lunch 11:00AM) *

Emergency Contact (Name/Relationship). *

Emergency Contact Phone *

Specify any food allergies, medications, instructions, etc. If not applicable, please type "N/A" *

Any additional questions/concerns/comments:

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