THE CITY OF MONTCLAIR EXPANDED LEARNING PROGRAM REGISTRATION FORM - SUMMER 2023

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11% of survey complete.

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* 1. School (Select only one)

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* 2. Check one or all:

Session I - All schools listed below (June 2 - June 23) Tentative, subject to change

Session II - Kingsley and Serrano Only (July 6 - July 26) Tentative, subject to change

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* 3. Student's First Name

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* 4. Student's Last Name

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* 5. Student's grade

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* 6. Student's age

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* 7. Student's date of birth

Please enter birthdate below

Date

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* 8. Student's ID#

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* 9. Student's teacher's name

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* 10. Student's gender

Male

Female

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* 11. Student's home address

Address

City/Town

State/Province

ZIP/Postal Code

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* 12. Student's ethnicity

Not Hispanic/Latino

Hispanic/Latino

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* 13. Student's race. Please select only one.

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* 14. Please enter the name (first and last) of the student's parent/legal guardian:

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* 15. What is the above person's relationship to the student?

Father

Mother

Step-Father

Step-Mother

Grandfather

Grandmother

Aunt

Uncle

Other (please specify)

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* 16. What is the above person's home address, email, and cell/home phone number?

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Cell/Home Phone Number

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* 17. What is the above person's work phone number?

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* 18. If applicable, please enter the name (first and last) of the student's second parent/legal guardian:

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* 19. What is the above person's relationship to the student?

Father

Mother

Step-Father

Step-Mother

Grandfather

Grandmother

Aunt

Uncle

Other (please specify)

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* 20. What is the above person's home address, email, and cell/home phone number?

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Cell/Home Phone Number

THE CITY OF MONTCLAIR EXPANDED LEARNING PROGRAM REGISTRATION FORM - SUMMER 2023

Question Title

* 1. School (Select only one)

Question Title

* 2. Check one or all:

Question Title

* 3. Student's First Name

Question Title

* 4. Student's Last Name

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* 5. Student's grade

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* 6. Student's age

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* 7. Student's date of birth

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* 8. Student's ID#

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* 9. Student's teacher's name

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* 10. Student's gender

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* 11. Student's home address

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* 12. Student's ethnicity

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* 13. Student's race. Please select only one.

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* 14. Please enter the name (first and last) of the student's parent/legal guardian:

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* 15. What is the above person's relationship to the student?

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* 16. What is the above person's home address, email, and cell/home phone number?

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* 17. What is the above person's work phone number?

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* 18. If applicable, please enter the name (first and last) of the student's second parent/legal guardian:

Question Title

* 19. What is the above person's relationship to the student?

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* 20. What is the above person's home address, email, and cell/home phone number?

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* 21. What is the above person's work phone number?