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Distanced Learning Registration
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)
6th
7th
8th
9th
10th
11th
12th
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
No
Will your child require personal protective equipment provided?
(Required)
Yes
No
Parent's Email
(Required)
Parent's Email
(Required)
Parent's Phone Number
(Required)
Parent/Student Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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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