Summer School Enrollment Form 2018
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Summit High School Summer School Registration Form 2018
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STUDENT INFORMATION
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Student's Last Name Student's First Name Student's Middle Name: Age:Grade:Gender:
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Ethnicity: (Please Mark Only One)Race: (Please mark ONE or MORE of the following)Student's email address:
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____ Hispanic or Latino ____ American Indian/Alaska Native ____ Black or African American
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____ Not Hispanic or Latino ____ Hawaiian/Other Pacific Islander____ White ____ Asian
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Date of Birth (Month/Day/Year) Birth City Birth State Birth Country Student's Cell Phone
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/ /
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SCHOOL INFORMATION
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Name of School Attended 2017-2018 School YearSchool Location (City, State, Zip Code, if known)
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PARENT/GUARDIAN/ADULT STUDENT (over 18) INFORMATION
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Primary Contact: Name (Last, First)___ OK to pick-up ___ Legal Custody ___ Lives with ___ Receives MailingsSecondary Contact: Name (Last, First)___ OK to pick-up ___ Legal Custody ___ Lives with ___ Receives Mailings
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Home AddressHome Address
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City State Zip CodeCity State Zip Code
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Mailing Address (if different from above)Mailing Address (if different from above)
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City State Zip CodeCity State Zip Code
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Home Phone (____Primary #)Work Phone (____Primary #)Home Phone (____Primary #)Work Phone (____Primary #)
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Cell Phone (____Primary #)Relationship to StudentCell Phone (____Primary #)Relationship to Student
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Email Address: Email Address:
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IN CASE OF EMERGENCY NAMES OF PERSONS OTHER THAN PARENT WHO CAN ASSUME TEMPORARY RESPONSIBILITY
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Emergency Contact 1 Name (Last, First) - Person that can Pick up StudentEmergency Contact 2 Name (Last, First) - Person that can Pick up Student
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Home PhoneWork PhoneHome PhoneWork Phone
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Cell Phone Relationship to StudentCell Phone Relationship to Student
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***STUDENT BACKGROUND*** IMPORTANT!!!HOME LANGUAGE SURVEY (as required by Arizona Department of Education)
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If parents separated/divorced, who has legal custody? _______________________________What is the primary language used in the home regardless of the language spoken by
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Does the non-custodial parent have restricted visitation rights? ____ Yes ____ Nothe student? _______________________________________________________________
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(If yes, a copy of the legal papers must be provided)What is the language most often spoken by the student? _________________________________
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Does your child currently receive extra services? ____ Yes ____ NoWhat is the language the student first acquired? _________________________________________
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___ Special Education/IEP ____ 504 ____ ELL or IEP PLEASE LIST SIBLINGS
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Does your child have medical or dietary concerns we should know about? ____ Yes ____ NoNames (Last, First) AgeSchool
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Has your child ever been expelled from another educational institution? ____ Yes ____ No1.
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Is your child currently in the process of being expelled from a school? ____ Yes ____ No 2.
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Is your child currently under a long-term suspension? ____ Yes ____ No 3.
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Has your child ever been a Leona Group student before? ____ Yes ____ No 4.
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TO THE BEST OF MY KNOWLEDGE THE INFORMATION I HAVE PROVIDED ON THIS FORM IS ACCURATE AND TRUE. (FALSIFICATION OF INFORMATION IS A CLASS 6 FELONY - A.R.S. 13-2-107) STUDENT WILL BE WITHDRAWN FOR FALSE INFORMATION
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PARENT / GUARDIAN / ADULT STUDENT SIGNATUREDATE
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What school is student planning on attending during the 2018-2019 school year?
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728 E McDowell Road, Phoenix, Arizona 85006 602.258.8959 www.summiths.com
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Summit High School - Summer School 2018
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Students are able to participate in one class per session. Perfect attendance is required for students to receive .5 credit for a class. Breakfast and lunch items will be provided daily for free. Classes are a total of ten days, Monday-Friday. Place an “X” next to the class you want to attend. If a student misses more than one hour of any class for any reason, they will not be able to earn credit. No accommodations will be made. Do not sign up for classes if you know you have a prior appointment. Classes are from 8:00 AM - 2:35 PM (Lunch: 11:30-11:50). Any discipline issues will not be tolerated, and students will be removed. Discounted bus tickets for Valley Metro Bus service are available upon request.
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Summer School Session #1: June 4 - June 15
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Biology 1 (Toscano)
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Financial Algebra (Padilla)
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World History 1 (Wright)
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A+ Computer Based (Fladager)
Choose a class from the list below
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Subject: Subject:
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English CreditMath CreditSocial Studies CreditScience Credit Elective Credit Fine Arts Credit
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English 9-1Algebra 1-1American History BiologyHealthArt Appreciation
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English 10-1Algebra 2-1Economics Earth Space ScienceLifetime Fitness/PECareer Essentials
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English 11-1Geometry 1GovernmentPhysical SciencePersonal FinanceHumanities
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English 12-1TrigonometryUS GeographyPsychology
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English 12-2World GeographySociology
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World History
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If a specific course is not listed, please write the course title here: __________________________________________________________
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The course will need administrative approval.
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Summer School Session #2: June 18 - June 29
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World History 2 (Wright)
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Biology 1 (Toscano)
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A+ Computer Based (Fladager)
Choose a class from the list above
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Subject: Subject:
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