Community Youth Advance · Saturday School Registration

Date of Application

*

(mm/dd/yyyy)

Student Information

Student Name

*

First Name

Last Name

Date of Birth

*

(mm/dd/yyyy)

Gender

*

Male

Female

Student ID Number

other

Current Grade

*

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Homeroom Teacher/Counselor Name:

Are you Hispanic or Latino?

Yes

No

Please check one or more ethnicities

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

White

Other

Primary Guardian’s Information

Name

*

First Name

Last Name

Relationship to Student

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Primary Phone Number

*

Work Phone

Cell Phone

State Issuing Driver’s License

Email

Secondary Guardian’s Information

Name

*

First Name

Last Name

Relationship to Student

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Primary Phone Number

*

Work Phone

Cell Phone

State Issuing Driver’s License

Email

Please answer the following questions in order to complete your application.

What areas of concern do you have regarding the applicant’s reading proficiency, math abilities or performance?

*

How would you best describe the applicant’s study habits?

*

How do you feel PGCPS Saturday School will benefit the applicant?

*

Please circle your student’s performance level

*

Reading

Please circle your student’s performance level

*

Math

Does your son/daughter have an Individual Educational Plan (IEP)?

*

Yes

No

Is student eligible for Free & Reduced Meals (FARM)?

*

Verification will be required.

Yes

No

Please include any information our staff should know about any learning needs, medical conditions, food allergies, IEP, or 504 accommodations that are needed for your child.

*

Payment

Registration Fee

*

$50

$35 - (Free And Reduced Meals (FARM) Eligible Only)

$45 - (Sibling Discount)

$31.50 - (Sibling & FARM Discount)

Confirm Your Student's Enrollment In Saturday School Program

*

CONFIRM

Media Release

Media Release - Throughout the school year Community Youth Advance via our partnership with Prince George's County Public Schools will conduct activities that may be publicized through local or national news media. These activities may include interview sessions with news reporters; photographs of individual students or groups of students for newspapers or various school system publications including newsletters, calendars, and brochures; the use of student photos on the Community Youth Advance web site; and videotaping for local and national television news programs, cable programming, and school system promotional videos.

I/we grant permission for my/our child’s name, voice, and photographic likeness to be used by Community Youth Advance personnel, or reporters, journalists, or photographers employed by news media.