Shifting Gears Registration (Summer 2022) Session 5

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Complete the form below. The email is the parent/guardian Preferred Email.

Email *

Confirm email (Please enter email again) *

Favor confirmar su correo electronico.

Parent/Guardian's First AND Last Name *

Nombre Y Apellido del padre/tutor

Students FIRST NAME *

Primer nombre del estudiante

Students LAST NAME *

Apellido del estudiante

Student's FCPS ID # (Write N/A if new to FCPS) *

Numero de ID del estudiante

Please confirm the session you are signing up for your student. (By checking, you are confirming you are signing up for that session) *

Confirme la sesión en la que se está inscribiendo para su estudiante. (Al marcar, está confirmando que se está registrando para esa sesión).

Session 5: Thursday, August 11th, from 8am-11am

Required

Elementary school your child attended for sixth grade. *

Escuela primaria a la que asistió su hijo en sexto grado.

Select a T-shirt size for your student. **All sizes are in adult sizes, we do not carry Youth.** *

Seleccione la talla de T-shirt de su estudiante. **Todas las tallas son de adultos y no de jovenes **

Name of Emergency Contact for Student *

Nombre de un contacto de emergencia para el estudiante

Emergency Contact Phone Number *

Telefono del contacto de emergencia

Relationship of Emergency Contact *

Relacion del contacto de emergencia con el estudiante

Does your student have any allergies, emergency medications, and/or medical needs that the staff should be aware of? *

Su estudiante tiene alergias? Toma medicaciones? Tiene alguna necesidad medica que el personal escolar deba conocer?

Is there anything else that we should know about your student? (examples-they have an IEP/504, they're new to the county, etc.) *

Hay algo importante que debemos conocer sobre el estudiante? (por ejemplo si tiene un plan de IEP/504; si son nuevos al pais, a la escuela, etc.)

Please indicate if you will need bus transportation for your student for Shifting Gears. *

Indique si necesitará transporte en autobús para su estudiante para cambiar de marcha.

Yes, my student will use bus transportation if available

No, I will drop off and pick up my student from Kilmer

A copy of your responses will be emailed to the address you provided.

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