Home › Resources › Summer School Information › 2019 Summer School Registration 2019 Summer School Registration 2019 Regional Summer School Program Student Application Step 1 of 7 14% EnrollmentProduct Name*Content Area (Primary)* English Math Science Social Studies Would you like to add a second content area?* Yes No Content Area (Additional)* English Math Science Social Studies Would you like to add a third content area?* Yes No Content Area (Additional)* English Math Science Social Studies Student InformationName* First Last Age* Year of Graduation* Sending School* Student Information - continuedStudent Phone (Primary)*Please provide a phone number best used to contact the student.Student Phone (Secondary)Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Same Physical Address? Yes No Physical Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian (Primary)Parent/Guardian Name* First Last Relationship*MotherFatherStep ParentGrandfatherGrandmotherAuntUncleBrotherSisterFriendOtherPhone (Primary)*Please provide a phone number best used to contact the parent/guardian.Phone (Secondary) Parent/Guardian (Secondary)Parent/Guardian Name First Last RelationshipMotherFatherStep ParentGrandfatherGrandmotherAuntUncleBrotherSisterFriendOtherPhonePlease provide a phone number best used to contact the parent/guardian.Phone Emergency ContactPlease provide a relative's name, phone and relationship that may be used in case of an emergency.Emergency Contact Name* First Last Relationship*MotherFatherStep ParentGrandfatherGrandmotherAuntUncleBrotherSisterFriendOtherPhone (Primary)*Please provide a phone number best used to contact the emergency contact.Phone (Secondary) Use of Vehicle Parental Consent I give my child permission to drive a private vehicle to the Regional Summer School.VehiclesMakeModelColorLicense Plate All students, faculty, and parent pick-up will occur in the back parking lot at the Messalonskee Middle School. Local bussing will run through the front lot and entrance. School hours are from 8-12; Monday-Thursday unless otherwise specified. I understand that driving privileges may be revoked by the Summer School administration for any driving infraction.I understand that payment is to be received in the amount of $130 to hold my child's enrollment in the 2019 program. If his/her PLP indicates additional courses, the cost for each additional course is $80.00 (3 course maximum). Please Note: Students will be allowed to withdraw from the summer program and receive a refund up until the registration deadline of June 28th, 2019, but not after. Summer School tuition will be forfeited upon any school policy violation (see rules sheet).Parent/Guardian Acknowledgement* I have read and understand all policies and procedures of the Regional Summer School Program. This form also serves as a records release allowing the sending school and summer school to communicate educational information related to your student. Submit this form to pay via Paypal or Credit/Debit Card. The total owed is show below.Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Expiration Date Security Code Cardholder Name Total $0.00
