Items denoted with a red asterisk * are required.
Student's Name
 
First Name
M.
Last Name
 
 
 
 * Grade as of September
 
 
 
 
 * Age
 
Sex
 
 
 
 
 * Name of School Student Would Be Attending
 
 
 
 
 
 
 
Parent(s)/Guardian(s) Name
 
Email
 
Address
 
Address 1
Address 2
City
State
Zip Code
Home Phone
 
 -  - 
(XXX)-XXX-XXXX
Work Phone
 
 -  - 
(XXX)-XXX-XXXX
Cell Phone
 
 -  - 
(XXX)-XXX-XXXX
Person Providing Instruction
 
First Name
M.
Last Name
Qualifications
 
Subject Areas to Be Covered
 
Curriculum to Be Utilized: (Please include textbook titles and lesson plans
 
Number of Days of Instruction
 
Number of Hours of Instruction
 
Method of Evaluation of Progress
 
 * This checkbox affirms my signature
 


By checking this box I affirm the information provided here is true and accurate. I understand my signature will be needed on this form before it is filed with School Committee for approval.