2019 HPS Extended School Year (ESY) Student Application
The Holyoke Public Schools will once again offer a variety of Extended School Year (ESY) Programs in the summer for children who qualify, as per their IEP. These programs are free of cost to all students who qualify, as per their IEP. If you are unsure which ESY program your child is being recommended for, please reach out to your child’s educational team leader at their school.

The program will take place Monday-Thursday. The hours of the program for the children will be 9:00 am to 1:00 pm begins Monday, July 8, 2019 to Thursday, August 8, 2019. Breakfast, lunch, & transportation will be provided to those who qualify for Extended Year Services on their IEP’s.

Please fill out the registration form if your child qualifies for ESY program, as per their IEP, and you are interested in having your child participate this summer. If you are unsure if your child qualifies for Extended School Year (ESY) services, please contact your child’s educational team leader at their school. If your child does not qualify for ESY services, please be sure to ask your school for information/registration forms for our free of cost Summer Learning Academies offered throughout the district.

No child will be admitted without up-to-date immunizations and current physical examination within the last 12 months.

YOU MUST REGISTER BY MAY 1, 2019 TO ENSURE TRANSPORTATION WILL BEGIN THE FIRST DAY

Email address *
Student's First Name *
Your answer
Student's Last Name *
Your answer
Student's Date of Birth *
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/
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/
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Student's Current Grade
Your answer
Student's Current School *
Child's Current Special Education Program *
Which ESY Program did your IEP Team Recommend? (If unsure, please contact your child's special education team leader at their school) *
Child's HOME Address *
Your answer
Child's PICK UP Address (if you are transporting your child instead of bus, please write "N/A" below) *
Your answer
Child's DROP OFF Address (if you are transporting your child instead of bus, please write "N/A" below) *
Your answer
Parent's Name(s) *
Your answer
Parent's Primary Phone Number *
Your answer
Parent's Secondary Phone Number
Your answer
NO CHILD WILL BE ENROLLED WITHOUT PROPER EMERGENCY INFORMATION. PLEASE LIST NAME & PHONE NUMBER OF EMERGENCY CONTACT OTHER THAN PARENT/GUARDIAN *
Your answer
Second Emergency Contact Name & Phone Number (optional)
Your answer
Is your child allowed to swim in public pools? *
May your child be photographed for newspaper, television, or social media?
How does your child communicate? *
Required
Does your child have seizure disorder or any other medical issue that staff should be monitoring? *
Your answer
Is your child allergic to any food? If yes, please specify which food(s). *
Your answer
Is your child allergic to animal stings or bites? If yes, describe treatment *
Your answer
Does your child have any other allergies? If yes, please describe the allergy and treatment. *
Your answer
Does your child take any medications? If yes, please describe
Your answer
Will your child be taking any medications during school hours? If yes, please describe. You will also need to submit doctor's note to your school nurse. *
Your answer
Is your child toilet trained? *
Is there anything else we need to know about your child to ensure a safe summer? If no, please write "NA" *
Your answer
A copy of your responses will be emailed to the address you provided.
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