Sign for Summer Academy

Our MES Summer Academy combines virtual learning with exciting activities to spark curiosity, build confidence, and make lasting memories.

Student Name:

First Name

Last Name

Dropdown

Gender:

Date:

YYYY

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 1:

First Name

Last Name

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Number:

Email:

Parent/Guardian 2:

First Name

Last Name

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Number:

Email:

Emergency Contact:

First Name

Last Name

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Number:

Email:

Relationship to student:

Health Insurance Carrier:

Identification Number:

Is the student currently under a doctor's / physician's care?:

Is the student currently taking sny medication?:

Does the student have any know allergies?:

If yes, please explain:

Are there any factor(s) that would prevent the student from full participation in daily activities?:

Physician:

First Name

Last Name

Number:

Escort 1:

First Name

Last Name

Number:

Relationship to student:

Escort 2:

First Name

Last Name

Number:

Relationship to student:

Sign for Summer Academy

MARVIN’S EDUCATION SERVICES