Rocky Hill Middle School # 707
Extended Year Program Registration
Please complete, sign and return to Lisabeth Belman at Rocky Hill Middle School by June 10, 2016.
PART I: To be completed by PARENT/GUARDIAN. PLEASE PRINT ALL INFORMATION.
Student MCPS ID Number
Gender (Enter number)
______________________________________
1= Male
2=Female
Student’s Last Name
_______________________________________________
Please let us know if your
student has one or more of these:
Age___
First Name_________________________________________
Parent/Guardian’s Last Name______________________________ First Name________________________________________
Phone: Home (_______) _______________________________
Work/Cell (_______) _______________________________
Email ____________________________________________________________________________________________________________________________________
Does this student have:
An IEP?
Grade
Yes
No
(in Sept.)
An ELL Plan?
Yes
No
An Epi pen?
A 504 Plan?
Yes
No
Yes
No
Address__________________________________________________________________________________________________________________________________________________________________________
Street
City
State
ZIP
Emergency Contact: Name_____________________________________________________________________________________Phone: H (______) ________________
W/C (______) ____________________
R
Name of Home School now attending
_____________________________________________________________________________________
Method of Transportation to Extended Year Program: Walk
Method of Transportation from Extended Year Program: Walk
School Bus
School Bus
Parent Drop-off
Parent Drop-off
Other
Other
Specify_________________
Specify
_
PART II: REGISTRATION- Please check the applicable course offering.
Support Math 6 (Course #0232) $95
(Incoming 6th Graders, 4 weeks)
Support IM (Course #0234-2) $95
(Invitation only for incoming 7th graders, 4 weeks)
Support Reading 6 (Course #0221) $95
(Incoming 6th Graders, 4 weeks)
Support Math 7 (Course #0234-1) $95
(Incoming 7th Graders, 4 weeks)
Bridge to Algebra (Course #0245-2) $75
(Invitation only for incoming 8th graders, 3 weeks)
Support Reading 7/8(Course #0223) $95
(Incoming 7th and 8th Graders, 4 weeks)
Select only 1 course.
Focus on Algebra (Course #0245-1) $75
(Incoming 7th and 8th graders taking Algebra next year, 3 weeks)
Select only 1 course.
PART III: TUITION PAYMENT – Attach check or money order for the FULL TUITION amount. If paying with credit/debit
cards, please visit the school’s Online School Payments website.
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Student may qualify for a tuition waiver. To apply, complete and attach to this registration form MCPS form 325-4: Application for Full Waiver of Summer School
Tuition. You can find this form at www.montgomeryschoolsmd.org/parents/ and please fill in sections for Middle School Program, not General Summer School.
Method of Payment
Check #
Amount $
(U.S. funds only) (Make check payable to Rocky Hill Middle School. Include Student name, ID number, and school name on checks.)
Money Order #
Cash $
Amount $
Do not mail. Cash payments should be brought to school and exact payment amount required.
Charge $
Please pay online at Rocky Hill Middle School Online School Payments website. Online payment is available using
credit/debit cards (Visa/MasterCard only).
Refunds:

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One day’s attendance makes a student ineligible for a refund. An exception to this is for the student who attends less than one week and must withdraw because of
hospitalization or home confinement for personal illness.
All requests for tuition refunds must be made prior to July 22, 2016.
PARENT’S/GUARDIAN’S SIGNATURE: Parent’s/guardian’s signature certifies that:___________________________________
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Student has met all immunization requirements.
Method of payment is assured and it is understood that a $25.00 fee will be assessed for returned checks.
The parent/guardian will inform the extended year coordinator of any custody issues; health issues or special accommodations required for the
student.
The student will comply with all rules and regulations of MCPS and the middle school summer school site.
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.
I understand that one day’s attendance makes a student ineligible for a refund. An exception to this is for the student who attends less than one week
and must withdraw because of hospitalization or home confinement for personal illness.
I understand that if 12 students do not register in this class by June 13, 2016, then the class will be cancelled and the registration fee will be
refunded.
Signature________________________________________________Date__________________________________________
Parent/Guardian