Summer School Manchester 2015 Registration Please print all information Last Name: _________________First Name: __________________ Birth Date: _____________ Circle One: Male Female

Are you a student with an identified disability? _____________*

Are you (or will you be) a high school graduate? ____________ Address __________________________________________________________________________ Home Phone # __________________________ Grade 20014/2015: _____________ Current School and address: ________________________________________________________ Parent (Guardian) Name 1: ______________________________ Daytime Phone: _____________ Parent (Guardian) Name 2: ______________________________ Daytime Phone: _____________ Parent/Guardian Email Address: _____________________________________ *Students with disabilities must attach a copy of their most recent IEP or 504 plan used during the 14-15 school year.

Please write your course selections below. Please list additional alternate courses in order to help ensure enrollment. Course Title Course Length Credit/Enrichment Course 1: ___________________________________________________________________________ Course 2:

___________________________________________________________________________

First Alternate: ___________________________________________________________________________ Second Alternate: ___________________________________________________________________________ Students must have approval of their home school in order to enroll in summer school. Your guidance counselor or principal must sign below indicating home school approval for course enrollment. Signature: ________________________________ Title: ____________________ Phone: ______________ Fees must be paid prior to the first day of attendance. Fees must be paid by cash, money order or bank check. Bank checks and money orders must be made payable to: Manchester School District. Mail or bring payments to: Central High School Attn: Alisha Hansen-Proulx, Summer School Director 207 Lowell Street Manchester, NH 03104 * For more information or any questions, please call the director of summer school, Alisha Hansen-Proulx at 603-624-6356.

FOR OFFICE USE ONLY DO NOT WRITE BELOW THIS LINE: Course(es) enrolled: __________________________________ ____________________________________ __________________________________ Amount Due: _________________ Amount Paid: ______________ Cash/Money Order/Bank Check Special Education: _____________ Plan Attached? __________ Section 504: ______________ Plan Attached? __________