CVA Regional Summer School 2023 Registration Form Parent Sign Off 
This form is for school counselors to share with parents to fill out for Regional Summer School 2023. 
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Email *
Student Last Name  *
Student First Name  *
Home District  *
Current Grade Level (2022-2023 SY)  *
Special Education (Check if you have...)  *
Required
Emergency Contact Last Name  *
Emergency Contact First Name  *
Emergency Contact Phone Number  *
Emergency Contact Relationship To Student  *
Please note any medical conditions staff should be aware of during Regional Summer School  *
By checking the box below I approve my child to attend Regional Summer School at Jarvis Middle School in Mohawk, NY. I agree to provide my child with the necessary materials needed for each course. I understand my child may utilize computer programs such as emails, internet, etc for appropriate educational purposes. I understand and agree that my child will not be allowed to drive/ride to Regional Summer School without special approval. My child may participate in picture taking activities that may be released to the news media. I understand my child will be required to sign and abide by the acknowledgement of student code of conduct. I authorize BOCES to take my child to the nearest emergency first aide station or hospital if necessary. I realize the school district can not assume responsibility for the payment or medical fees or expenses incurred. If my child must be taken home and neither parent can be reached, please call the listed emergeny contact.  *
Required
We (Student and Guardian) agree to abide by the Code of Conduct and acknowledge agreement with the RSS Code of Conduct that was provided via email or paper copy to each student. We agree to turn in the Acknowledgment form on July 10, 2023.  *
Required
Medical Authorization Forms  

I attest that my child does take medication during the established school day and I agree to complete the appropriate Medical form for Physician Authorization of Administration of Medication and return it to the home district by June 30, 2023, during school business hours.
 *
Computer Authorization Agreement or Students 
I have read the policy for access to electronic telecommunications. I understand and will abide by the terms, conditions and guidelines. I further understand violation of the regulations is unethical and may constitute criminal offense. Should I commit any violation, my access and privleges may be revoked, disciplinary action may be taken and/or appropriate legal action.
 *
Required
Computer Authorization Agreement for Parents 
I agree as a parent or guardian of this student that I have read the terms, conditions, and guidelines in the Policy and Regulation of Access to Electronic  Telecommunications. I understand that this access is designed for educational purposes and the Herkimer BOCES has take available precautions to eliminate controversial material. However, I also recognize it is impossible for Herkimer BOCES to restrict access to all controversial materials and I will not hold them responsible for the materials acquired through the network. Further I accept full responsiblity for supervision if and when my child''s use of an issued device is not in a school setting. I hereby give permission to issue an account for my child and certify that the information contained in this form is correct.
 *
Required
Name of Person Completing the Form  *
A copy of your responses will be emailed to the address you provided.
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