Employee Name: _______________________________

SOUTH COBB HIGH SCHOOL

T.S.A. (Teach, Service, Accelerate) Summer Program

August 1-5, 2011

REGISTRATION & TRANSPORTATION FORM

STUDENT INFORMATION (Please print)

Name:

Address:

City and Zip Code:

Zoned High School:

Current Middle School:

SLC or Small School:

PARENT INFORMATION (Please print)

Name Guardian/Mother:

Name Guardian/Father:

Address:

Address:

City and Zip Code:

City and Zip Code:

Home Phone Number:

Home Phone Number:

Cell Phone Number:

Cell Phone Number:

EMERGENCY CONTACT INFORMATION (Please print)

Emergency Contact Person:

Address:

City and Zip Code

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Parent Consent:

I agree for my son/daughter to participate in the 9th Grade Transition Program: “TSA” Summer Academy 2011. I understand that all student participants are expected to be present daily and punctual during the duration of the summer program – August 1-5, 2011. I give permission for my son/daughter to participate in all program related activities including field trips and the use of the internet. Brochures, newsletter, and other publicity materials about the program may be published or aired. I hereby give consent for my child’s name, likeness, pictures, and/or voice to be used by the South Cobb High School and the news media. I release South Cobb High School of any medical or legal liability.

Student Consent

I understand that I am expected to adhere to the following policies, procedures, and guidelines associated with TSA 2011:

· Arrive on time each day.

· Attend the program each day.

· Attend at least 50% of each day to receive certificate of completion. Parents are encouraged to schedule personal early release times after 10:30am. Excessive early release times may result in the student’s dismissal from the Summer Transition Program.

· Adhere to South Cobb High School’s Dress Code. Appropriate dress, neatness and cleanliness are expected of all students. Any article of dress that draws unfavorable attention, interferes with daily instruction, threatens health or safety of other students and/or staff are prohibited. Student will be sent home for inappropriate dress.

· Behave in accordance to the CCSD rules and regulations as stated in the student handbook.

Consumption of food/beverages and chewing gum in the classroom are prohibited. Serious misbehavior such as gross disrespect to faculty and staff, use of profanity, cutting classes, gambling, leaving class or school without permission, carrying or possessing firearms, knives, weapons of any kind, distribution or possession of drugs, use of drugs, and deliberate acts of vandalism, will result in immediate dismissal from TSA 2011.

OVER

Please list any medical conditions and/or concerns_______________________________________________________

__________________________________________________________________________________________________.

Transportation Information

Please check the following method of transportation your student will be using for the TSA Program 2011:

|_| Walking |_| Automobile

My signature below denotes that I have reviewed and agree to the information printed on this registration form.

___________________________________________________________________________

Signature of Parent/Guardian (Required)Date

Failure to return a completed form may result in arrangements not being made for your child.

FOR SCHOOL USE ONLY:

To be completed by teacher/counselor

SST: Yes No D.O.B.

ESOL-M: ESOL:

PEC Eligibility: |_| LD|_|OHI|_| EBD|_|M/D|_|Other