Summer School Registration Form
THE LEARNING VILLAGE HUB
Program Selection
Which Summer Program are you registering for?
Summer Academic Enrichment
Credit Recovery
GED Preparation
Reading Intervention
Math Intervention
Entrepreneurship Camp
Workforce Readiness
STEM Exploration
Other
Session Selection
Session 1: June 1-June 27, 2026
Session 2: July 6- August 1, 2026
Full Summer Program
Preferred Attendance Format
In-Person
Online
Hybrid
Student Verification
Student Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Parent/Guardian Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency Information
Emergency Contact Name
First Name
Last Name
Relationship to Student
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical & Safety Information
Does the student have any medical conditions we should be aware of?
No
Yes- Explain below
If Yes, Please Explain:
Does the student have any allergies?
No
Yes- Explain below
If Yes, Please Explain:
Does the student take medication during program hours?
No
Yes- Explain below
If Yes, Please Explain:
Transportation
How will the student arrive?
Parent Drop-Off
Self Transportation
Public Transportation
Type option 4
Other
How will the student leave?
Parent Drop-Off
Self Transportation
Authorized Pick-Up
Authorized Pick-Up List
Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Technology Access
Will the student need assistance accessing:
Computer
Internet
Educational Software
None
Student Goals
What would you like your student to accomplish this summer?
Improve Grades
Catch Up Academically
Earn Credits
Prepare for GED
Build Confidence
Learn Job Skills
Explore Career Paths
Other
Parent Expectations
I understand that:
Attendance is important.
Communication with staff is required.
Students are expected to participate respectfully.
Program schedules may be adjusted as needed.
Media Release
May photos/videos be used for educational and promotional purposes?
Yes
No
Signature
Parent/Guardian Signature
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: