Office of Extended Learning                            Student Registration Form 2022 -2023
THIS FORM IS FOR PARENTS OR GUARDIANS ONLY - Students should NOT be filling out this form
ALL FIELDS ARE REQUIRED TO MAINTAIN OUR GRANT FUNDING 
Sign in to Google to save your progress. Learn more
Email *
Student Name *
Date of Birth *
MM
/
DD
/
YYYY
Lives with? *
Gender (optional)
Transportation Home (pickup or needs transportation) *
Address *
Home Phone Number *
Parent/Guardian Email *
ADDITIONAL EMERGENCY CONTACT INFORMATION - PLEASE ENTER NAME AND (working) PHONE NUMBER *
School attending *
Grade level *
Teacher (Math or English) *
Planned Start Date *
MM
/
DD
/
YYYY
Days attending: Students attending Monday-Friday will receive priority registration.
Photograph permission: I give permission for Laconia School District Office of Extended Learning to use, without limitation or obligation, photographs, voice recordings, or film footage for program use and/or for purposes of occasionally promotion program activities *
Medical Information - If you answered yes to any of the below, is an emergency plan necessary and on file with the school? *
Required
Any other information we need to know about? (pickup restrictions, special needs, etc.) *
AUTHORIZATION AGREEMENT:
I have CAREFULLY read the above Authorization Agreement and agree with all terms listed. *
By providing your electronic signature below, you hereby certify that all of the information is true and correct to the best of your knowledge. Please fill in your name and today's date. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Laconia School District. Report Abuse