September 30, 2004 - Isaac E. Young Middle School

IEYMS SUMMER ACADEMY PROGRAM
REGISTRATION FORM
Deadline: June 13, 2012
Student’s Last Name:
________________________________
Student’s First Name:
________________________________
Name of School:
________________________________
Current Grade Level
House (1,2,3)
___________________________________
___________________________________
Name of Parent/Guardian:
___________________________________
Address:
___________________________________
___________________________________
___________________________________
Telephone:
_____________________________________
Emergency #:
Email Address
Does your child have any allergies
_____________________________________
_____________________________________
_________
If yes, please list.
__________________
Does your child have any other medical conditions of which we should be aware _________
If yes, please explain.
_________________________________________
** As a reminder, summer school ends at 12:30pm each day. Please make arrangements for your child to either
walk home or be picked up by an adult.