BSHS Summer School Application

Summer School Application

Berkeley Springs High School
Purpose: Credit Recovery for BSHS students

Dates: June 6 - July 15, 2022

Summer credit recovery is recommended for students who have failed one or more core courses for the school year.

If you have any questions please contact:
Mitch Nida at 304-258-2871 x103 or mnida@k12.wv.us
Mike Wilder at 304-258-2871 x168 or mwilder@k12.wv.us
Child's Name *

First Name Last Name
WVEIS ID Number
Sex *

Male Female
Race *

Hispanic Origin White Black/African American Asian American Indian/ Alaskan Native Pacific Islands
Birthdate *

Month Day Year
Date
Age *
Current Grade Level *
For which courses are you requesting credit recovery? *
Custodial Parent/Guardian *

First Name Last Name
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Day Phone *
Please enter a valid phone number.
Cell Phone *
Please enter a valid phone number.
Email *
example@example.com
Second Parent/Guardian

First Name Last Name
Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Day Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Persons to contact in case of emergency if parent/guardian can't be reached:
Name *

First Name Last Name
Phone *
Please enter a valid phone number.
Name

First Name Last Name
Phone
Please enter a valid phone number.
Who can pick up your child from BSHS Summer School?

*The person will be asked to show a form of ID when picking up your child.
Name

First Name Last Name
Relationship to Student
Phone
Please enter a valid phone number.
Name

First Name Last Name
Relationship to Student
Phone
Please enter a valid phone number.
During BSHS Summer School, photographs or tapes may be made of children in the program which could be used in the newspaper, on our website, or in publicity about the program. Your signature gives permission to use photographs or tapes of your child. Your answer does not affect your child’s participation in BSHS Summer School. Check the ones we may use: *

Photographs Audio Video
Parent/Guardian Signature

Clear
Should be Empty:

Summer School Application

Persons to contact in case of emergency if parent/guardian can't be reached:

Who can pick up your child from BSHS Summer School?