Summer Literacy Program 2024 Application

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Email *

Child's Name *

Child's Birthdate *

Child's Current Grade *

Child's School and District *

Child's Teacher

Caregiver's Name *

Cell Phone *

Address *

Emergency Contact Name *

Emergency Contact's Phone *

Does your child receive additional assistance in:

Reading

Math

Resource

Speech

Other:

Please describe your child's learning and school experience to date: *

What are your goals for your child's education? *

During the course of the Literacy Program, we will be filming your child on videotape as well as taking photographs. These may be used for instructors’ professional portfolios and future promotions for the Literacy Program and/or the Teacher Education Department at Roberts Wesleyan University. Your child’s name will not be included. I hereby give my permission to have videotapes and/or photographs taken of my child. Please sign electronically below. *

Given the limited instructional time and targeted focus of the Summer Literacy Program, I understand that my child’s attendance is necessary. I also understand that if his/her behavior significantly disrupts the learning environment, my child will not be allowed to continue participation in the Summer Literacy Program. Please sign electronically below. *

Send me a copy of my responses.

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