After School Project Promise Program

If you are interested in attending the 2017 High School Summer Program with us, fill out the form below.

 

Please fill out the form below.
If you prefer, you can print out this form and return to main office.

Name
Grade Currently enrolled in for the 2017/18 School Year:
 9th
 10th
 11th
 12th
Gender:
 Female
 Male
Ethnic Origin of Child:
 American Indian/Alaska Native
 Asian/Pacific Islander
 Hispanic or Latino
 Black or African American
 White or Caucasian American
 Other

Is your child eligible for Free and Reduced Lunch?
 Yes
 No

Is your child enrolled in extracurricular activities?
 Yes
 No

If your child has extracurricular activities, what Days / Time
 Mon
 Tue
 Wed
 Th
 Fri

Is your child enrolled in LEP or ESOL program?
 Yes
 No

If Yes, how would you best specify your child’s need/disability? Please check all that apply:
 Autism Spectrum Disorder
 Chronic Medical Condition
 Emotional or Behavioral Disorder
 Hearing Impairment (Or Deaf)
 Intellectual Disability
 Learning Disability
 Physical Disability
 Speech/Language Impairment
 Visual Impairment (Blind)
 Other Disability:

Has your child been retained?
 Yes
 No


Are any other siblings being registered?
 Yes
 No
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