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Section 1 - Student Demographic Information
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* Indicates required question
Email
*
Your email
Group Limit
There is a 25 student limit for each grade level. Registrations will be accepted on a first come basis. The registration date and time will be recorded for each form submitted.
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Grade Level
*
Choose
October - 5th Grade ONLY
November - 4th Grade ONLY
January - 3rd Grade ONLY
February - 2nd Grade ONLY
March - 1st Grade ONLY
Your Child's Homeroom Teacher
*
Your answer
Parent's Name
*
Your answer
Additional Parent Email Address (other than the email address already listed)
Your answer
Parent's Phone Number
*
Your answer
Additional Parent Phone Number
Your answer
Are there any allergies, medical conditions that Ms. Faust needs to be aware of for this program? (information is confidential and will not be shared)
severe allergies
medical condition
IEP
504 Program
Behavior Intervention Plan
Other:
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