General James Gholson Middle School
Extended Learning Year
Registration Form
Student Name:______
Student ID #:______Grade as of the 2015/2016 SY:______
D.O.B: ______Age ______Male ______Female_____
Parent/Guardian Name:______
Parent/Guardian Phone Number:______
Parent/Guardian email______
Student/Parent/Guardian Address:
______
______
Transportation Needs: Walker______Car Rider______Bus Rider______
Is the address listed above the pickup and drop off address?______
If not, please list the drop off information below.
______
Emergency Contact Name: ______
Emergency Contact Phone Number:______
I ______am registering my scholar in the 2015 Extended Learning Year program that will be held from 8:30am - 3:00pm, at Gholson Middle School, from July 6th- July 30th (Monday-Thursday). By signing below, I am agreeing to my scholar attending ALL 16 summer learning sessions. Moreover, the scholar will ADHERE to appropriate behaviors outlined in the student rights and responsibilities handbook, provided by PGCPS, during the 4 week program.
Student / Scholar Signature:______
Parent/Guardian Signature:______
****THIS FORM IS DUE TO THE GUIDANCE OFFICE AT GHOLSON BY MARCH 20TH***
Applications must be received/postmarked no later than Friday, March 20, 2015. Please mail application to:
G. James Gholson, Attention Extended Learning Summer School Coordinators,
900 Nalley Rd , Landover, MD
20785
Additional Questions please email:
Dr. Crystal Caballero or Emily Madison
or
Medications:
______
Allergies:
______
My scholar has a 504 ______(please check)
My scholar has an IEP ______(please check)
My scholar needs ELL services______(please check)
Student Interest: ______
Additional information about your scholar:
______
Rising Scholar Information
Feeder School:
______
Extra Curricular Activities:
______
Creative Arts Interest:
______