ESY 2019 APPLICATION

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Applications received after April 30, 2019 are not guaranteed first week program attendance.

Email *

Student Last Name *

Student First Name *

Date of Birth *

YYYY

Attendance *

Will Be Attending

Will Not Be Attending

Current Grade *

Current School of Attendance *

Current Case Manager *

My child is eligible for ESY in current IEP *

Yes

Father/Guardian name *

Mother/Guardian name *

Contact Number *

Parent/Guardian Confirmation

I wish to register my child for the special education program offered this summer. I expect, at this time, that our summer plans will not conflict with my child's regular attendance for the extended year program. By entering my initials below, I confirm that I am the parent and/or legal guardian of the aforementioned student. I further acknowledge that I have read and understand the following:

Acknowledgement *

I will notify my child's current school site of any changes to demographics, emergency contacts and/or medical alerts

I will notify my child's current school site if I no longer intend to send my child to ESY-2019

Required

Enter initials *

Send me a copy of my responses.

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