Check the Rose Tree Media School you attended either in person or virtually in 2023-2024. *
Required
Student's Age *
Your answer
Grade Entering in the 2023-2024 School Year *
Required
My child currently receives special education services through the Rose Tree Media School District (i.e. IEP). *
Required
Child living with *
Required
Child's Parents *
Required
Primary Physical Custodial Parent/Guardian *
Your answer
Special Custodial Court Instructions *
Required
If yes to the above question, please explain.
Your answer
Guardian 1 Name *
Your answer
Guardian 1 Date of Birth *
MM
/
DD
/
YYYY
Guardian 1 Address *
Your answer
If the address for Guardian 1 differs from the student's, can RTMSD/RTMCyber Academy release information?
Guardian 1 Home / Cell Phone *
Your answer
Guardian 1 Email (Please check for accuracy when entering prior to submitting registration). *
Your answer
Guardian 1 Employer's Name
Your answer
Guardian 1 Business Phone
Your answer
If applicable, Step-parent's Name
Your answer
If applicable, Step-parent's Phone
Your answer
Is Guardian 1 the primary household you would like to appear in the RTMSD/RTMCyber Academy Student Management System? *
Guardian 2 Name
Your answer
Guardian 2 Date of Birth
MM
/
DD
/
YYYY
Guardian 2 Address
Your answer
If the address for Guardian 2 differs from the student's, can RTMSD/RTMCyber Academy release information?
Guardian 2 Home / Cell Phone
Your answer
Guardian 2 Email (Please check for accuracy when entering prior to submitting registration).
Your answer
Guardian 2 Employer's Name
Your answer
Guardian 2 Business Phone
Your answer
If applicable, Step-parent's Name
Your answer
If applicable, Step-parent's Phone
Your answer
Is Guardian 2 the primary household you would like to appear in the RTMSD/RTMCyber Academy Student Management System?
Clear selection
If the student is living with Guardian(s) other than the parent(s), please provide the Guardian(s) Name, Address, Home / Cell Phone, and email below.
Your answer
Please describe any medical alerts, serious illness, or disabilities. Please type NONE if not applicable. *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number during the Day *
Your answer
By checking yes, you hereby declare that you are a resident of the Rose Tree Media School District and reside at the address listed on this form. You understand that the district has the right to investigate the validity of the statement including using videotape surveillance. *
Required
Is the student currently a English Language Learner? *
Your answer
If yes to the above question, please specify the language(s) spoken primarily in the home.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Rose Tree Media School District. Report Abuse