2022-23 ESMEC BVP Application

2022-2023 ESMEC Blended Virtual Program *Waitlist*

Student Application Form Grades 6-12
This application is to participate in the Eastern Shore of Maryland Educational Consortium's Blended Virtual Program for the 2022-23 school year. The ESMEC BVP is open to all students enrolled in a public school located in one of the seven participating counties on the Eastern Shore of Maryland – Caroline, Dorchester, Queen Anne’s, Somerset, Talbot, Wicomico, and Worcester. The program is for students who will be enrolling in grades 6 – 12 for the 2022-23 school year.

If the student was not enrolled in a Maryland Public School for the 2021-22 school year, you will need to enroll them in their local school of record (the school they would attend based on the student's address). The following documents will need to be provided to enroll (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.
Student Information
Student Name *

First Name Last Name
County of Residence *
This must be where the student will be living during the 2022-23 school year.
Student Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Student Phone Number
(If different from parent/guardian)
Student Email
example@example.com
Date of Birth *

Month Day Year
Date
Gender *

Female Male Other
Ethnicity/Race *
Did the student participate in the ESMEC BVP for the 2021-22 school year? *

Yes No
School Attended for the 2021-22 School Year *
Local School of Record for 2022-23 *
This is the school the student would attend if in person based on the student's physical address.
Grade Entering for the 2022-23 School Year *
The following questions are for informational purposes only and responses will not determine student acceptance into the program.
Does the student have a computer? *

Yes No
Does the student have reliable access to internet? *

Yes No
Will an adult be available with the student during school hours? *

Yes No
Is the student currently receiving special education services? *

Yes No
Does the student have an active IEP? *

Yes No
Does the student have a 504 plan? *

Yes No
Does the student have an English Language Learner Plan? *

Yes No

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 lead to successful academic outcomes for your student? *
Is there any additional information you would like to share about your student?
Parent/Guardian Information
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 *

Phone Email Other
Acknowledgment
By signing and submitting this form:
1. 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 2022-23 school year.
2. I understand that submission of this application does not guarantee admission into the program.
3. 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.
4. I allow my child's school records to be shared with employees of the Blended Virtual Program as needed.
5. If accepted into the program, I will ensure that the student will have reliable and consistent internet access available daily.
6. I understand that the BVP is a minimum commitment of one (1) semester.
7. If accepted into the program, my child and I agree to abide by all policies and procedures for the ESMEC BVP and the local school system.
8. I understand that the local school system may require a student to return to in-person learning due to poor attendance, poor grades, discipline problems, or other reason as determined by the local school system.
Parent Signature *

Clear
Date Signed *

Month Day Year
Date
Should be Empty:

2022-2023 ESMEC Blended Virtual Program *Waitlist*

Student Information

Parent/Guardian Information

Acknowledgment

2022-2023 ESMEC Blended Virtual Program Waitlist