Extended Student Services (ESS) Wait List Form

ESS Family Information and Waitlist Form

Please complete the form below. As space becomes available, a program coordinator will contact you.

Primary Family Email Address

Preferred Language

Address

City

State/Province

Zip Code

Parent 1

Mother's Name

Mother's Email Address (if different from the Primary email address)

Mother's Primary Phone

Mother's Secondary Phone

Parent 2

Father's Name

Father's Email Address (if different from the Primary email address)

Father's Primary Phone

Father's Secondary Phone

Please list all children below:

Child #1

Child #1 Name (required)

Child #1 Birth Date (required)

Child #1 Year Starting (required)

Child #1 Grade (required)

Child #1 Home School (Select 1) (required)

Child #2

Child #2 Name

Child #2 Birth Date

Child #2 Year Starting

Child #2 Grade

Child #2 Home School (Select 1)

Child #3

Child #3 Name

Child #3 Birth Date

Child #3 Year Starting

Child #3 Grade

Child #3 Home School (Select 1)

Child #4

Child #4 Name

Child #4 Birth Date

Child #4 Year Starting

Child #4 Grade

Child #4 Home School (Select 1)

General Information

Is your child already attending an LVJUSD school?

Yes

Do you think you qualify for subsidy assistance?

Yes

Tuition assistance is based on a sliding scale.

If you feel you may be eligible for tuition assistance, please indicate your total gross family monthly income

If you feel you may be eligible for tuition assistance, please indicate you family size: #Adults/#Children

Comments or Questions

Your application will be dated upon receipt and you will be contacted when there is an opening at your home school site or the school your student is currently enrolled in.

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ESS Family Information and Waitlist Form

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