Did you????
□Complete the STEAM Summer Camp Application
□Attach a copy of your most recent report card or an unofficial transcript (used for academic evaluation and course placement)
□Sign and date photo release forms
□Sign and date the Wellness Center waiver form
□Sign, date and attach thePAR-Q form
□Scholar Submission Statement
□Include payments
Bridgeport Organization for Youth Sports, INC.
STEAM Summer Camp at Housatonic Community College 2016 Application
Science, Technology, Engineering, Art and Math
Name of Scholar: ______Date of Birth: ____/_____/______
Mailing Address:______
Phone Number: ______Gender: Female Male
Current School: ______Grade completed in June 2016: ______
Race/Ethnic Background (optional): ______
Parent 1: ______Occupation: ______
Mailing Address: ______
Cell Phone Number: ______Work Number: ______Home Number: ______
Email Address:______@______
Parent 2: ______Occupation: ______
Mailing Address: ______
Cell Phone Number: ______Work Number: ______Home Number: ______
Email Address:______@______
Emergency Contact Name: ______Emergency Contact Number______
Are there any physical conditions that we need to know about?
Allergies Diabetes Asthma ADD/ADHD Heart Condition Other:______
If yes briefly explain: ______
Scholar Submission Statement: Briefly describe your academic interests. Also include how you would like this STEAM camp to help you reach your future goals? (You may attach additional sheets)
______
______
______
______
Academic and Athletic Schedule-
- Academics will be held at Housatonic Community College
- Hands-on academic workshops that build college readiness in Science, Technology, Engineering, Art and Math (STEAM).
- Scholars will spend time developing their self-esteem, confidence, professionalism, team building challenges, and key presentational skills necessary for success.
- Scholars will work with college professors and staff who promote a learning environment where scholars are encouraged but at the same time uniquely challenged to be creative thinkers and problem solvers.
- The afternoon portion of the curriculum is dedicated to physical fitness and training at the HCC Wellness Center and designated off-site field houses with trained athletic coaches.
Check the appropriate session:
Session One: (5 weeks) 6/20/16-7/22/16 grades 6-9th -Monday to Friday 8:00 am to 4:00 pm
Session Two: (5 weeks) 7/25/16-8/26/16 grades 10- 12th- Monday to Friday 8:00 am to 4:00 pm
Payment Schedule:
Payment cost per session $550 (includes all expenses, uniform, academic fees and more)
Breakfast and Lunch will be provided; students are welcome to bring a healthy snack
Checks made payable to:BOYS, Inc. Summer Camps
Care for Kids Applicants- please submit the appropriate documentation.
Cancellation Policy and Returned Check Policy:if a check or e-check payment is returned by a financial institution for any reason, such as insufficient funds, closed account or stop payment, a returned payment charge will be placed on the student’s account.
The following returned payment charges will be assessed:
Check Amount Fee
Up to $50, returned payment fee of $25
$51-$300, returned payment fee of $30
$301 and Up, returned payment fee of $40
•A $100 late payment fee will be charged to the student’s account, if the check was issued to pay for tuition.
HCC Photo Model Release
I give my permission Connecticut Community Colleges, which includes Housatonic Community College, to use, without compensation of any kind, my name and/or photographs of me or my child for publicity, promotional, or advertising purposes in all forms and media (for example, newspapers, TV, brochures, posters, and other forms and media) and in all manners, including composite representations, for trade, educational, or any other lawful purposes of the System of Connecticut Community College’s choice.
The permission I grant herein includes my consent under the Family Educational Rights and Privacy Act (FERPA) to disclose as part of my education record my name and photographic image for the purposes and in the manner stated herein. I hereby release and discharge the Colleges of the System of Connecticut Community Colleges and their agents, officers and employees from any claims, suits, or liability whatsoever for invasion of privacy, distortion or alteration of photographs, libel, slander or otherwise in such use. I waive any right to inspect or approve the finished product, including written copy, that may be created in connection therewith. I have read this release and am fully familiar with its contents. (If under age 18, parent or guardian must also sign.)
Signature: ______Date: ______
Print Name: ______
Address: ______
City: ______State: ______Zip:______
Telephone: ______
Parent Name (if under 18):______
Parent Signature (if under 18): ______
Bridgeport Organization for Youth Sports (BOYS), Inc.
P.O. Box 5992
Bridgeport, CT, 06610
Permission to Use Photograph
Subject: ______
Location: ______
I grant to BOYS, Inc. its representatives and employees the right to take photographs of me and my property in connection with the above-identified subject. I authorize BOYS, Inc. its assigns and transferees to copyright, use and publish the same in print and/or electronically.
I agree that BOYS, Inc. may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
I have read and understand the above:
Signature ______
Printed name ______
Organization Name (if applicable) ______
Address ______
Date ______
Signature, parent or guardian ______
(if under age 18)
Housatonic Community College Wellness Center Rules
STEAM Summer Academy/STEAM Saturday Academy
Housatonic Community College is pleased to welcome you to our new state-of-the-art Wellness Center. The Wellness Center is a part of student and campus life at Housatonic Community College. The Wellness Center is free for all HCC faculty, staff, and registered credit students. At this time HCC does not offer community memberships.
Mission Statement
The HCC Wellness Center is a state-of-the-art fitness facility that is committed to improving the general well-being of all patrons. We encourage safe and effective exercise in an effort to improve one's quality of life.
Hours of Operation: Differ each semester. Please check with the Wellness Center each semester for operational hours.
The Wellness Center is closed on official State of Connecticut holidays. The Wellness Center is located in room 117 in the Beacon Hall Building. Wellness Center Phone (203) 332-5134; Student Life Office Phone: (203) 332-5094. The Wellness Center is available for STEAM Summer Academy participants and instructors only. The Wellness Center hours of operation will coincide with the hours of operation for the STEAM programs.
Wellness Center Rules & Regulations
All patrons must present be signed up with the Housatonic Community College and Bridgeport Organization for Youth Sports, INC STEAM program. All patrons must view the equipment manufacturer’s DVD on how to use the equipment and complete a set of forms prior to using the Wellness Center. This will include an Informed Consent Form, an Activity Waiver Form and a Par-Q & You self-assessment Health Form, for our records. It is asked that these forms be accurately and completely filled out. These forms will be filed and kept confidential.
1. You must be supervised by a staff member working with the Housatonic Community College and Bridgeport Organization for Youth Sports, INC STEAM program.
2. No tobacco, drugs, alcohol or illegal substances of any kind are allowed in the facility.
3. You are expected to act in a courteous and respectful manner. You are required to follow the instructions of the Wellness Center staff at all times. Profanity, yelling, rude or boisterous behavior will not be tolerated.
4. Clean, dry sneakers must be worn when working out. No street shoes, bare feet, boots, sandals, dress shoes, cleats or other types of footwear may be worn.
5. Proper athletic clothing must be worn when working out. Shirts and shoes must be worn at all times. Jeans, jean shorts, khakis and excessively loose fitting clothing are not allowed. Apparel with ornamental zippers, chains, rivets or buckles are not permitted.
6. The Wellness Center staff reserves the right to determine what constitutes appropriate athletic attire.
7. Daily use lockers are available. HCC is not responsible for lost or stolen items. For safety and security reasons, if you are not comfortable leaving your bag and personal items in the Daily Use Lockers, please secure your personal items in your car or at home.
8. The Student Life Office will determine the music selection on the center's sound system. Personal stereos and headsets are allowed. No boom boxes.
9. With the exception of water and sports drinks, no food or beverages are allowed in the center or studio at any time. No glass containers are allowed.
10. There is a total time of 1 (one) hour allowed per person per day on the machine(s) in the Wellness Center.
11. No equipment is to be moved from its designated area and none may be taken out of the Wellness Center.
12. It is your responsibility to follow all posted rules. Please ask the staff on duty if you have any questions or need assistance.
13. Individuals under the age of 18 are not permitted in the weight and cardiovascular room without adult supervision and parental consent.
14. All equipment must be wiped down by each participant after use.
15. Showers are available for your use. Soap, shampoo and towels are not provided. Please bring your own supplies.
16. Report all damaged or broken equipment to a HCC Wellness Center staff member immediately.
17. Use of this fitness facility is considered a privilege. Individuals who do not comply with the established policies will be asked to leave and may have this privilege revoked.
Thank you for agreeing to follow the above Rules and Regulations. If you have any questions, please call the Student Life Office at 203.332.5094. Thank you.
I read and do agree with the above Wellness Center Procedures.
______
Printed Name
______
Signature Date