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BOARD OF COOPERATIVE EDUCATIONAL SERVICES 2010-11 Summer School Course Registration
Directions: Your home school principal or guidance counselor must approve your registration by signing this registration form. CLASSES WILL BE OFFERED CONTINGENT ON SUFFICIENT ENROLLMENT. If a class is low enrolled (14 or less students), there will be a surcharge assessed. If a class does not run due to low enrollment, you may be offered a seat in another program. Please see Summer School Administration for more information. PLEASE DO NOT FORGET TO COMPLETE AND ATTACH THE MEDICAL INFORMATION FORM TO THE REGISTRATION FORM WHEN SUBMITTED. A LINK FOR THE MEDICAL INFORMATION FORM CAN BE FOUND ON THE REGISTRATION COMPLETION PAGE.

Any fields noted with a *  are required. All data collected in this form will be handled according to the guidelines set forth in our privacy policy.
*  Student Name
  Last Name:
  First Name:
Email:
 
*  Mailing Address
  Street:
  Apartment Number:
  City:
  State:
  Zip:
*  Date of Birth:
(ex: mm/dd/yy)
*  Sex: M F
*  Social Security Number:
(ex: 111-22-3333)
*  09-10 Grade in School:
*  Home School Name:
*  School District Residency:
*  Name of Parent/Guardian:
*  Home Phone:
(ex: 111-222-3333)
*  Emergency Phone:
(ex: 111-222-3333)
Special Education Yes No
IEP MUST BE ATTACHED
SUMMER SCHOOL COURSE REQUEST(S)
Course 1:  

*** For any New York State Exam NOT related to your assigned course(s) you must register for that exam separately.
Course 2:    

PRINCIPAL'S APPROVAL

I approve the above summer school registration. The student indicated above has completed all appropriate pre-requisite
courses. All state required immunizations have been received.

Print Principal's or Guidance Counselor's Name
Home School Phone Number
(ex: 111-222-3333)
Date
(ex: mm/dd/yy)
PARENTAL CONSENT 
Payment must be made by money order or bank check
payable to the district where the student registers.

Cash and personal checks will not be accepted

If your child does not attend the course for which they are scheduled, no refund will be given.

You agree that your child will follow the summer school site's Code of Conduct regarding discipline and attendance.

If you are a NON-DISTRICT RESIDENT or a STUDENT FROM A NON-PARTICIPATING DISTRICT, the student is to
pay the amount listed for each district, per course, Central Islip - $199.83; East Islip - $225.45; Patchogue-Medford $240.38; Riverhead $265.78.

If the course has low enrollment, there will be an additional surcharge. The student will be responsible for this surcharge. No grades will be released until all fees have been paid.
Non-Discrimination Statement
The Eastern Suffolk BOCES does not discriminate against any employee, student, applicant for employment or candidate for enrollment on the basis of
gender, race, color, religion or creed, age, national origin, marital status, disability or any other classification protected by law. For further information or
concerns regarding this statement, please contact the Eastern Suffolk BOCES Department of Human Resources at (631) 687-3029.
MEDICAL FORM MUST ACCOMPANY REGISTRATION FORM
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