EmailMe Form - 2018 Summer School Student Registration

Time: On-site: 8:00am to 12:00pm (Monday - Friday)

201 East St. Clair Street, Eaton, OH 45320
Term: June 4 - June 29.

Summer School cost is $200 plus a $7.00 processing fee for online registration. Registration is not completed without payment. Payment is due prior to the first day of summer school.

Step One: Student Information

Parent/Guardian Name *

First Last

Parent/Guardian Email *

Student Name *

First Last

Where will the student be completing this course? *

At the Alternative School

Online exclusively

Student's Email: Students who are not taking a course on-site must have an email address. The ESC can provide one if needed.

Home or Cell Phone *

### - ### - ####

Secondary Phone

### - ### - ####

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Current School District *

If School District is "Other," Please Provide the District's Name or Other Description.

2017-2018 Grade Level of Student *

Course Offerings: Please indicate which course the student will be taking. Only one course may be taken at a time. Once the student completes one course, a request to take another course may be submitted. *

Please indicate if this class is for full-credit or half-credit. Full-credit courses are $200 each. Half-credit courses are $100 each. *

Full-credit

Half-credit

Please indicate which semester of the given subject the student will be taking. If unsure, contact your schools guidance counselor.

Semester 1

Semester 2

Course is only half credit

Do you have any special instructional needs? *

Yes

No

Please describe the IEP plan and attach a copy of the IEP or 504 plan. *

Please upload a copy of the IEP or 504 plan. *

Emergency Medial Form: Please upload the completed Emergency Medical Form.

You can download this form at: http://www.preblecountyesc.org/Documents/EmergencyMed.pdf

Parent/Guardian Acknowledgment
By checking this box, I verify that I have read and understand the Summer School Student Code of Conduct for the Summer School Program. *

Parent/Guardian Verification

Download the Summer School Student Code of Conduct at: http://www.preblecountyesc.org/Documents/summerschoolcodeofconduct2018.pdf

Student Acknowledgment
By checking this box, I verify that I have read and understand the Student Code of Conduct for the Summer School Program. *

Student Verification

PAYMENT OPTIONS: How do you wish to pay for summer school classes? *

Credit Card - Online and includes a $7.00 processing fee

Check - Payment must be made at the ESC office (597 Hillcrest Dr., Eaton) 937-456-1187

If you wish to pay by check, please complete the registration form and submit it. After submission, you will be taken to a site to complete the payment process. DO NOT COMPLETE THE ONLINE PAYMENT PROCESS. Registration will be recorded but you will still be required to make payment at the ESC office.

Payment Acknowledgement *

I understand that I must still make payement in full at the ESC office for my summer school registration to be completed and my child enrolled in summer school