Distanced Learning Registration

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BSM will host a Distance Learning hub for students to complete homework and receive tutoring/help with class. Please complete the form to register for Distanced Learning. Please complete one form per student.

Student Name(Required)

First Last

Student's Email(Required)

Student's Grade(Required)

Student Courses

Please select all of the courses your child is enrolled in

Math

Science

English (ELA)

Social Studies/History

Electives

Would you like to allow Resurgence staff to view grades and progress reports for your child?(Required)

Yes, Resurgence Staff can view my child(ren)'s grades

No, Resurgence Staff cannot view my child(ren)'s grades

Will transportation be needed?(Required)

Yes, I live further than 1 mile from The Youth Center (1034 Bridge St NW)

No, I live walking distance (1 mile or less) from the Youth Center

Has anyone in your household tested positive, or been exposed to someone who tested positive, for COVID-19?(Required)

Yes

Will your child require personal protective equipment provided?(Required)

Yes

Parent's Email(Required)

Parent's Phone Number(Required)

Parent/Student Address

Street Address Address Line 2 City State ZIP Code

Would you (the parent) like to volunteer?

Yes, I would like to oversee Distanced Learning

Yes, I would like to volunteer with Afternoon Labs

Yes, I would like to volunteer for both Distanced Learning and Afternoon Labs

Not at this time

Would you like to refer a family or friend to Resurgence?

Please provide their name and phone number

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Last Name
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