Middle School (School # 562 )

Extended Year Program Registration

Instructions: Please complete, sign and return to RedlandMiddle School by6/6/14

PART I: To be completed by PARENT/GUARDIAN. PLEASE PRINT ALL INFORMATION.

Student MCPS ID Number Race/Ethnic Group (Enter number) Gender (Enter number) Date of Birth

1. American Indian or Alaskan Native 3. African American 1= Male

2. Asian or Pacific Islander 4. White 5. Hispanic 2=Female

Student’s Last NameFirst Name MI

Parent/Guardian’s Last NameFirst NameMI

Phone: HomeWork

Area CodeArea Code

Address______Street City State ZIP

Emergency Contact: Name______Phone: H (______) ______W (______) ______

Name of HomeSchool now attending ______

Method of Transportation to Extended Year Program: Walk School Bus Parent Drop-off Other Specify

Method of Transportation from Extended Year Program: Walk School Bus Parent Drop-off Other Specify

PART II: REGISTRATION- Please check the applicable course offering.

Support Math 6 (Course #0232) $95 Support Reading6 (Course #0221) $95 Support Reading/ESOL (Course #0221) $95

(Incoming 6th Graders) (Incoming 6th Graders) (Incoming 6, 7, 8th Graders)

Support Math 7 (Course #0234) $95 Support Reading 7 /8 COMBO (Course #0223) $95

(Incoming 7th Graders) (Incoming 7th Graders)

Focus on Algebra (Course #0245) $75

(Incoming 6th, 7th and 8thGraders)

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.

  • Student may qualify for a tuition waiver. To apply, complete and attach to this registration form MCPS form 325-4: Application for Partial or Full Waiver of Summer School Tuition.

Method of Payment

Check # Amount $(U.S. funds only) (Make check payable to______Middle School. Include

Student name, ID number, and school name on checks.)

Money Order # Amount $ (Make payableto ______Middle School. Include

Student name, ID number, and school name on money order.)

Cash $ Do not mail. Walk in only.

Charge $ Please pay online at

Middle School Online School Payments website. Online payment is available using credit/debit cards (Visa/MasterCard only).

Refunds:

  • 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.
  • Allrequests for tuition refunds must be made prior to July 25, 2014

PARENT’S/GUARDIAN’S SIGNATURE: Parent’s/guardian’s signature certifies that:

  • Student has met all immunization requirements.
  • Method of payment is assured andit 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, 2014, then the class will be cancelled and the registration fee will be refunded.

Signature______Date______

Parent/Guardian