WRAP Virtual Fall Registration City of Long Beach

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Please fill out this form for Fall WRAP. The site director of the selected site will contact you to complete your registration and give virtual program instructions.

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Adres e-mail *

Select WRAP Fall site *

Student Name (first and last) *

Student Date of Birth *

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Student ID

Student Grade in 2020-2021 *

Parent/Guardian Name (first and last) *

Parent/Guardian phone number *

Parent/Guardian email *

Emergency contact name *

Emergency contact phone *

Release for permission to participate in the evaluative survey. *

Yes, I agree to all my student to participate in any evaluative survey related to the WRAP program.

No, I do not agree to all my student to participate in any evaluative survey related to the WRAP program.

Release for permission to photo, video, and sound record.

I hereby release, discharge, and agree to hold harmless the Long Beach Unified School District and those acting under its permission from any liability to the extent permitted by law, for the preparation, distribution, and use of photos, videos, and/or sound recordings.

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