24-25 Summer Learning Academy                 Student Registration Form       

The Summer Learning Academy is a collaboration between Project EXTRA (Office of Extended Learning),  Extended School Year Services through Special Education and Teacher Referrals. 

We will use the timestamp of when this registration form was received to place children into the remaining open spots. Once all spots have been filled, we will create a waitlist. 

Confirmations will go out at the end of May.  

THIS FORM IS FOR PARENTS OR GUARDIANS ONLY 
ALL FIELDS ARE REQUIRED TO MAINTAIN OUR GRANT FUNDING 
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Email *
Student last name: *
Students first name:
Date of birth: *
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Grade level (as of next school year): *
Current school: *
Street address: *
Who does your child live with? *
Parent phone number *
Parent/Guardian email *
Emergency contact name with phone number *
My child will be attending *
If you selected other please specify:
Transportation home (pickup or needs transportation): *
Medical concerns we should be aware of: *
Required
If other please specify
Any other information we need to know about? (pickup restrictions, special needs, etc.) *
Does your child have an IEP or 504? *
Photograph permission: I give permission for the 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 occasional promotion program activities. *

NH State Policy governing the administration of non-academic surveys or questionnaires (RSA 186:11, IX-d) now requires written consent of a parent or legal guardian, unless the student is an adult or an emancipated minor, before a student is allowed to participate.  

Laconia School District receives grant funding from the Nita M. Lowey 21st Century Community Learning Centers to administer programming through the Office of Extended Learning.  These programs include: Expanded Learning Opportunities (ELOs), enrichment, clubs and and Student Leadership Team at Laconia High School, REAL Initiative programs and clubs at Laconia Middle School, Project EXTRA and PIQUES at all three elementary schools, and summer programming at Laconia Schools. The 21st CCLC grant requires an annual student survey for continued funding. 

If your child(ren) participate in ANY of these programs, we will be seek your permission. We appreciate your cooperation with this process.


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Is there anything that you would like us to know?
AUTHORIZATION AGREEMENT:

I give my permission for my child(ren) to go to: Opeechee Point Beach (or Bond Beach), Laconia. I understand this is a daily walking trip. 1st, 2nd and 3rd grades will leave at 12:30 and return at 1:45pm, 4th and 5th grade students will be leaving around 1:35 and will arrive back at 2:50. Please send your child prepared with: bathing suit, towel, water bottle (labeled with student name), snack, sunscreen, sneakers.  I am aware that my child may need additional help with applying sunscreen and give permission for an adult to help if needed. (Scheduled times are subject to change. Parents/guardians will be notified about these changes ahead of time.) 


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Please give us the best cell phone number to reach you.  *
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. *
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