Summer Journey Registration Form
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Email *
Student's First Name *
Student's Middle Name *
Student's Last Name *
Student's 24-25 Grade Level *
Student's Birth Date *
MM
/
DD
/
YYYY
Student's Address (include physical address if using P.O. box for mail) include city, state, and zip code *
Parent/Guardian Name *
Parent/Guardian Home Phone  *
Parent/Guardian Preferred Contact Phone Number
(Cell, Home Phone, Work Number)
 *
Parent/Guardian Alternative Contact Phone Number *
E-mail Address *
Emergency Contact (Name and Phone Number)
 *
Ethnicity
 *
Gender
 *
Current School Name
 *
AM Transportation
 *
If AM bus, please list address of pick up. If car mark NA.
 *
PM Transportation
 *
If PM bus, please list address of drop off.  If car mark NA.
 *
Health problems or concerns
 *
If yes, please describe,. If no mark NA.
 *
Is your child currently taking medication at school?
 *
If yes, List Drug(s). If no mark NA. *
Is your child allergic to anything? *
If yes, please identify. If no, mark NA. *
Will your child need medication during Summer School? *
Name of Drug
*child must have a medical form on site
N/A in it does not apply
 *
Name and phone number of physicians(s) *
In case of accident or serious illness, I request school personnel to contact me, alternate authorized person(s), or the named physician. If it is impossible to contact me, authorized persons, or the physician, the school personnel may make emergency arrangements as necessary to care for my child.  *
Hospital Perference *
I will allow any pictures taken of my child during summer school to be posted on the schools social media.  *
Do you plan to enroll your child in swim lessons? If yes, a link will be provided after you submit this form in the confirmation page.  *
My typed signature is my written permission for my child to attend Osage County R-II Summer School Program. *
A copy of your responses will be emailed to the address you provided.
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