Roberto Clemente Middle School (School #
157
)
Extended Day Program School Registration
Instructions: Please complete, sign and return to Laura Crittenden
by 10/30/14
PART I: To be completed by PARENT/GUARDIAN. PLEASE PRINT ALL INFORMATION.
Student MCPS ID Number
Race/Ethnic Group (Enter number)
Gender (Enter number)
1. American Indian or Alaskan Native 3. African American
2. Asian or Pacific Islander 4. White 5. Hispanic
Date of Birth
1= Male
2=Female
Student’s Last Name
First Name
MI
Age
Parent/Guardian’s Last Name
First Name
MI
Grade
(in Sept.)
Phone: Home/Cell
Work
Area Code
Does this student have:
An IEP?
Yes
No
An ELL Plan?
Yes
No
A 504 Plan?
Yes
No
Area Code
Address__________________________________________________________________________________________________________________________________________________________________________
Street
City
State
ZIP
Emergency Contact: Name_____________________________________________________________________________________Phone: H (______) ________________
C (______) ____________________
R
Method of Transportation:
Walk
School Bus
Other
Specify
PART II: REGISTRATION- Please check the applicable course offering.
Support Math 6
Support Math 7
Support Algebra Prep Math 8
Lights, Camera, Literacy PLUS!
Support Reading Combo 6
PARENT’S/GUARDIAN’S SIGNATURE: Parent’s/guardian’s signature certifies that:
 The student will comply with all rules and regulations of MCPS.
 The parent/guardian understands that this highly concentrated program necessitates consistent attendance. Therefore, parent/guardian and
students commit to making full time attendance a priority.
 Excessive absences may be cause for removal from the extended day program.
 I understand that if 12 students do not register in this class by one week prior to the start date, then the class will be cancelled and the
registration fee will be refunded.
Signature________________________________________________ Date__________________________________________
Parent/Guardian
Signature________________________________________________ Date__________________________________________
Parent/Guardian