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Waiting List El Modena HS 9-11th Grade Summer School Consent 2021
Session A June 15- July 1 Session B July 5- July 21
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Email
*
Your email
Last Name
*
Your answer
First Name
*
Your answer
ID Number
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Male or female
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Male
Female
Parent or Guardian Name
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Your answer
Phone number
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Your answer
Emergency contact
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Your answer
Family Physician Name and Number
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Your answer
Parent email
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Your answer
Student email
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Your answer
If school personnel are unable to contact any of the above, permission is granted for medical care to be given as required( the parent/guardian will assume responsibility for fees involved)
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yes
No
I understand that if my student has more than 2 absences or fails to complete work, he/she will be dropped from summer school.
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yes
No
Parent Signature
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Your answer
DATE
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MM
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DD
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YYYY
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