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2022-2023 RTMCyber Academy Enrollment
Student Information Packet for CURRENT Rose Tree Media School District Students wishing to enroll in Edmentum, Rose Tree Media School District's online academy.
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* Indicates required question
Date of Registration
*
MM
/
DD
/
YYYY
Student's Legal Last Name
*
Your answer
Student's Legal First Name
*
Your answer
Complete Address
*
Your answer
Home/Cell Telephone
*
Your answer
Sex
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Ethnicity/Race
*
American Indian/Alaska Native
Asian
Black/African American
Hawaiian/Pacific Islander
Hispanic
Multi-Racial
White/Caucasian
Required
Check the Rose Tree Media School you attended either in person or virtually in 2021-2022.
*
Rose Tree Elementary School
Indian Lane Elementary School
Media Elementary School
Glenwood Elementary School
Springton Lake Middle School
Penncrest High School
Simon Youth Academy
Special education school through the District
Required
Student's Age
*
Your answer
Grade Entering in the 2022-2023 School Year
*
First
Second
Third
Fourth
Fifth
Sixth
Seventh
Eighth
Ninth
Tenth
Eleventh
Twelfth
Required
My child currently receives special education services through the Rose Tree Media School District (i.e. IEP).
*
Yes
No
Required
Child living with
*
Guardian 1
Guardian 2
Both
Other
Required
Child's Parents
*
Single
Married
Separated
Divorced
Widow/Widower
Required
Primary Physical Custodial Parent/Guardian
*
Your answer
Special Custodial Court Instructions
*
Yes
No
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?
Yes
No
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?
*
Yes
No
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?
Yes
No
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?
Yes
No
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.
*
Yes
No
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
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