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MYRON B. THOMPSON ACADEMY SUMMER SCHOOL
1040 Richards Street, Suite 220
Honolulu, Hawaii 96813
Phone: (808) 441-8000
www.ethompson.org
Summer School 2015 Registration Checklist
Registration will not be complete until all documents are received at MBTA by May 8, 2015
Please TYPE or PRINT CLEARLY – Do not leave any fields blank. Write “N/A” where no information is available.
___________________________________________________________________________________
Secondary - Grades 9-12, School Year 2015-2016

SUMMER SCHOOL 2015 REGISTRATION CHECKLIST (PAGE 1)

PAYMENT: Check, Money Order, OR Cash in Hand
Please payment out to: Myron B. Thompson Academy – Summer School
* Tuition must be paid in full when the application is submitted
* Returned checks will incur a $25.00 return check fee. *

STUDENT PERSONAL DATA & PARENT/GUARDIAN CONTACT INFORMATION (PAGE 2)

REGISTRATION FORM WITH STUDENT & PARENT SIGNATURES (PAGE 3)
Student Name:_____________________________________School SY14-15:__________________________
Please check the following requirements that apply to you: (these are requirements)




I have daily access to a computer with high speed internet
I have word processing, spreadsheet programs and email on my computer
I understand how to use the programs above
I agree to complete the Online Training by June 2nd
Submit all Documents by May 8, 2015:
Myron B. Thompson Academy
Summer School Division
1040 Richards Street, Suite 220
Honolulu, Hawaii 96813
FOR OFFICE USE ONLY
Username:
Session
Password:
ACCN
Training Course Completion Date:
Course
Instructor
Grade
Credit
Enrolled
****** For Office Use Only ******
Receipt No.:
_______________________
Received by: _____________________
Amount Paid: _______________________ CHK Alu Like
Check Number: _______________________ CSH
MO
Date of Receipt: _____________________
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STUDENT PERSONAL DATA
Last Name: ______________________________________________
Gender: M
First Name: ______________________________________________
Grade Level: _______ SY 15/16
Middle Initial: _________
Birth date: ____________________
Lineage: (Jr., II, III, etc.): _________
F
Home Phone: __________________________ Email: _______________________________________________
The Student MUST provide a valid email address – Gmail addresses are preferred. Yahoo.com addresses will be accepted
If ever a DOE Student, MUST provide DOE Student Number (10 digits): _____________________________________
Physical Address:
Number
Street
City
Apt. #
State
Zip Code
Island
Mailing Address: (If different from physical residence)
Number
Street
City
Apt. #
State
Zip Code
Island
PARENT/GUARDIAN CONTACT INFORMATION
MOTHER / GUARDIAN
FATHER / GUARDIAN
It is the parent’s / guardian’s responsibility to inform the school of any changes.
Check One: Mr. Mrs. Ms.
Other (Specify): _______
*Relation to student: _______________
*Last Name: _______________________
*First Name: _________________________
*Home Phone: ______________________
*Cellular or Pager: _____________________
Work Phone: ______________________
*Email: _________________________________________
*Child lives with contact:  Yes
Check One: Mr. Mrs. Ms.
 No
* Educational Custody of Child: Yes
Other (Specify): _______
No
*Relation to student: ________________
*Last Name: _______________________
*First Name: __________________________
*Home Phone: ______________________
* Cellular or Pager: _____________________
Work Phone: ______________________
*Email: __________________________________________
*Child lives with contact:  Yes
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 No
* Educational Custody of Child: Yes
No
rev.3-5-2015
REGISTRATION FORM WITH PARENT/GUARDIAN & STUDENT SIGNATURES
 School to receive grade(s) & credit(s) – School attending for SY 2015-2016:
 Myron B. Thompson Academy
 Other School :_______________________________________
Mailing Address :____________________________________
____________________________________
 I am currently receiving special education services:
 Yes
 No
 Other:__________
Reasons for Attending Summer School:
 Please select MBTA enrollment status:
 Current MBTA student – counselor approval required 1. Grade and Credit Recovery ( 7-12)
2. Grade Improvement 7th Grade
 Current TEA student
3. Scheduling Conflict
 New MBTA Applicant for SY2015 / 2016
4. Acceleration or Early Graduation
 None of the Above / Summer School Only
5. Other: _____________________________
___________________________________________________
Course 1 – Title & ACCN Code
Reason Code (Circle One):
1
2
3
4
5
___________________________________________________
Course 2 – Title & ACCN Code
Reason Code (Circle One):
1
2
3
4
5
___________________________________________________
Alternate Course 1 – Title & ACCN Code
Reason Code (Circle One):
1
2
3
4
5
___________________________________________________
Alternate Course 2 – Title & ACCN Code
Reason Code (Circle One):
1
2
3
4
5
I have read all the requirements to participate in the MBTA Summer School Program, and I confirm that I have met all
requirements. I will complete the mandatory Online Training by June 2nd, and I understand that my continued
enrollment is dependent on my completion of this Online Training.
I agree to check my email daily and communicate with my instructors as needed via MBTA email, phone or though
Canvas (course website). I understand that the MBTA Summer School course(s) I am registering for will be reflected
on my transcript at the school which I have designated on this application.
If I choose not to continue with a course, I must complete and submit the withdrawal form to MBTA’s Summer School
Director on or before June 2nd [received in office/email - no postmarks], or I forfeit the refund and risk receiving an “F”
on my permanent record. I understand that NO REFUNDS will be processed after June 2, 2015.
Student signature:
________________________________ E-mail ____________________________ Date _____________
Parent signature:
________________________________ E-mail ____________________________ Date _____________
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