ESMEC Elementary BVP Application

The ESMEC BVP is open to all students enrolled in a public school located in one of the nine counties on the Eastern Shore of Maryland. The program is for students who will be enrolling in grades K-5 for the 2021-22 school year. If you select your district and the application does not appear, please contact your local school system for additional information. If the student was not enrolled in a Maryland Public School for the 2020-21 school year, the following documents will need to be provided to your local school system prior to enrollment in the program: (1) birth certificate, (2) proof of residency, and (3) immunization records. Space in the program will be limited. For more information on the program, please visit www.easternshorevirtual.org.

County of Residence*

This must be where the student will be living during the 2021-22 school year.

If you have a student in grades K - 5 interested in remaining virtual for the 2021-22 school year, please contact your local school or visit www.easternshorevirtual.org/contact for more information. Thank you.

Student Name*

First Name Last Name

Student Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

School Attended for the 2020-21 School Year*

School Attending for 2021-22 School Year*

(Or planning to attend)

Grade Entering for the 2021-22 School Year*

Please visit www.easternshorevirtual.org/apply to access the application for students in grades 6 -1 2.

Does the student have a computer?*

YesNo

Does the student have reliable access to internet?*

YesNo

Will an adult be available with the student during school hours?*

YesNo

Is the student currently receiving special education services?*

YesNo

Does the student have an active IEP?*

YesNo

Does the student have a 504 plan?*

YesNo

Does the student have an English Language Learner Plan?*

YesNo

Please rate the student on a scale of 1-5*

	1 Poor	2 Below Average	3 Average	4 Above Average	5 Excellent
Commitment to schoolwork
Time management
Focus (in a group setting)
Focus (in an independent setting)
Willingness to ask for help
Computer skills
Communication skills
Organization skills
Study habits

Why would the ESMEC Blended Virtual Program be a good fit for this student?*

Parent/Guardian Name*

First Name Last Name

Relationship to student*

(Father, Mother, Guardian, etc.)

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Best way to contact you*

PhoneEmailOther

By signing and submitting this form:

I acknowledge that submission of this form indicates my decision to have my child be considered for attendance in the ESMEC Blended Virtual Program for the 2021-22 school year.
I certify that my child is not, and will not, be enrolled in another public school, a non-public school, or a private school at the same time while participating in the Blended Virtual Program.
I allow my child's school records to be shared with employees of the Blended Virtual Program as needed.
If accepted into the program, I will ensure that the student will have reliable and consistent internet access available daily.
I understand that submission of this application does not guarantee admission into the program.

Date Signed*

Date

Parent Signature*

Clear

ESMEC Blended Virtual Program

Student Information

Parent/Guardian Information

Acknowledgment