Northshore School District

Secondary Summer Academy




Step :
Items denoted with a red asterisk * are required.
 
 
Please note: this is a two-page form. After completing form, you will be directed to the page to submit payment. You will need to re-enter some of the information such as student name and address. If you experience any difficulty registering for Secondary Summer Academy, please contact the registrar at 408-6011 or ssummerschool@nsd.org.
 * First Initial Last
 
First Name
M.
Last Name
 * Address
 
Address 1
Address 2
City
State
Zip Code
 * Birthdate
 
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 * Current Grade
 
 * Parent/Guardian Name
 
 * Parent Home Phone
 
 -  - 
(XXX)-XXX-XXXX
Parent Work Phone
 
 -  - 
(XXX)-XXX-XXXX
 * Parent Email
 
 * Emergency Contact Name #1
 
 * Emergency Contact Phone
 
 -  - 
(XXX)-XXX-XXXX
 * Emergency Contact Name #2
 
 * Emergency Contact Phone
 
 -  - 
(XXX)-XXX-XXXX
 * Physician's Name
 
 * Physician's Phone
 
 -  - 
(XXX)-XXX-XXXX
 * School Student is Currently Attending
 
 * Student's High School Counselor
 
 * Student's CURRENT Identification # (found on report card or transcript)
 
 * Is this student in Special Education?
 
 * Is a '504' in place?
 
 * Does your child have a life-threatening condition?
 

Students with life-threatening conditions must have medications, medication authorization, and a school nurse plan in place the first day of Credit Retrieval.

Describe any health problems or special needs, including allergies
 
Vehicle License #
 
Car type/model