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Student Registration
Student Registration
ENGLISH
SPANISH
Step
1
of
3
33%
Student Information
First Name
(Required)
Last Name
(Required)
District
(Required)
Select
Archoe Union School District
Coalinga-Huron Joint Unified School District
King City Union School District
Linden Unified School District
Livingston Unified School District
Lodi Unified School District
North Monterey County Unified School District
Orland Unified School District
Salinas City Elementary School District
Salinas Union High School District
Stockton Unified School District
Other
School
(Required)
Grade
(Required)
Select
K
1
2
3
4
5
6
7
8
9
10
11
12
Other District
Gender
(Required)
Select
Male
Female
Other
DOB
(Required)
Month
1
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12
Day
1
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Year
2025
2024
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2015
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1920
Program Choice
(Required)
Select Program
Jump Into Math
Jump Into English
Undecided
Other
Program Code
Other
Does the student currently attend the school provided After School Program?
(Required)
Yes
No
Does the student currently receive any Special Education services? (Speech, Academic Support, Counseling, etc.)
(Required)
Yes
No
Does the student currently receive direct 1:1 assistance during the school day?
(Required)
Yes
No
Does the student have any significant medical needs that require a specialized health plan at the school?
(Required)
Yes
No
If YES to any of the above, please provide details regarding the student’s special education services, accommodations, and/or school site heath plan.
Parent/Guardian Information
Student Lives With
(Required)
Select
Both Parents
Mother
Father
Guardian
Other
First Name
(Required)
Last Name
(Required)
Email Address
Language Spoken
Select
English
Spanish
Other
Cell Phone
(Required)
Work Phone
Parent 2
First Name
(Required)
Last Name
(Required)
Email Address
Language Spoken
Select
English
Spanish
Other
Cell Phone
(Required)
Work Phone
Local Emergency Contact(s)
Name
(Required)
First
Last
Relationship
(Required)
Phone
(Required)
Name
(Required)
First
Last
Relationship
(Required)
Phone
(Required)
Name
First
Last
Relationship
Phone
Medical Condition(s) / Allergies
Are there any additional medical condition(s) or allergies that we should be aware of?
(Required)
Select
No
Yes
If Yes, Please Explain.
(Required)
After Tutoring
My student will:
(Required)
Be picked up from tutoring by someone on this form (Parent, Guardian and/or Emergency Contact).
Be dismissed by JIM Enterprises to the school provided After School Program.
Walk home from tutoring. I release all liability from JIM Enterprises.
Other
If other, please explain.
(Required)
Photo Release Authorization
I give permission for my student’s photo to be taken for promotional materials.
(Required)
Yes
No
Additional Student Information
Please provide any additional information that would help us provide your student with the best support.
Signature
(Required)
October 15, 2024
Phone
This field is for validation purposes and should be left unchanged.
