Registration Packet
Registration Directions
Registration Due Date: June 27, 2011
1. Complete pages 3 and 4 of the registration packet.
- Three (3) signatures are required to register your child.
- Program Participation Permission
- Short-term Illness and Medical Emergencies
- Media Release Permission
2. Keep pages 1 and 2 for your records.
3. Return the registration form to your child’s school by June 27, 2011.
**Program availability is limited. The completion of a registration packet does not guarantee acceptance to the program. **
Program Information
Grade Levels: 3rd – 6th
Program Dates
Math/Science/Language Arts
Dates: July 5 – 29, 2011
Sites: School 1, School 6/APA, School 8, School 9, School 10, School 13, School 18 (grade 6 only), School 20, School 21, School 24, School 25, School 26, School 27, School 29, Martin Luther King, Jr. School and Norman S. Weir School-
Students from School 4 and 28will attend School 28, Students from School 5, 14 and 19 will attend School 5, Students from School 12 (grade 3-5 only) and Urban Leadership Academy will attend School 12, Students from School 11 and 15 will attend School 15, Students from Edward W. Kilpatrick School and Alexander Hamilton Academy will attend Edward W. Kilpatrick, Students from New Roberto Clemente School and Roberto Clemente School will attend New Roberto Clemente
Time: 8:00am – 12:00pm
- Breakfast and lunch will be provided.
- Transportation – School busing
Student Behavior
- All students are expected to behave appropriately during the program.
- All school rules, regulations, and consequences will apply to the students according to student code of conduct manual.
- If the student does not behave appropriately, a phone call will be placed home to the parent.
- If the student continues to behave inappropriately, the student will be removed from the program.
Attendance
- Extended and excessive absences in the Elementary District Summer Program will result in losing the student’s seat in the program.
- If the student is aware of an upcoming absence, they should tell the on site Lead Teacher.
Clothing and Attire
- Students are expected to wear appropriate school clothing.
- If in doubt – do not wear it.
- Hats, hoods, and sunglasses are not permitted to be worn in any school building.
- Comfortable footwear must be worn.
What to Bring
- A great attitude ready for learning and fun.
- A small bottle of water (optional).
What Not to Bring
- Friends and siblings who are not attending the program
- Food (breakfast and lunch will be provided)
- Electronic devices: iPod, video game devices, etc.
Please complete thisform in its entirety and return to your child’s schoolby June 27, 2011.
Student InformationStudent Name: / Grade Level:
School: / Home Address:
Home Telephone #: / Student ID #(to be completed by school):
SRI Score (to be completed by school): / ELL Score (to be completed by school):
Parent Information
Mother Name: / Father Name:
Mother Address: / Father Address:
Mother Home Telephone #: / Father Home Telephone #:
Mother Cell #: / Father Cell #:
Emergency Contact Information
Name: / Relationship to Student:
Telephone #: / Address:
Additional Information
1. How will your child arrive to school in the morning?
2. How will your child get home from school in the afternoon?
3. Does your child wear eyeglasses?
4. Does your child take any medications? If yes, please specify.
5. Does your child have any allergies? If yes, please specify.
6. Is your child asthmatic?
Program Participation Permission # 1
Yes, I give my child, ______, permission to participate inPaterson Public Schools’ District Elementary Summer Programfrom
July 5, 2011 through July 29, 2011.
Parent/Guardian’s Signature ______Date ______
Short-Term Illnesses and Medical Emergencies # 2
Medication will not be given for any pre-existing short-term illness or infection on field trips. Children who are ill must remain home and rest. Parents will be contacted in case of serious sickness or accident; however, if an emergency situation that requires immediate medical attention occurs, I understand that my child may be taken via ambulance to the nearest hospital before I or my designated emergency contacts am contacted. Please provide two (2) emergency contact phone numbers where a parent, guardian or authorized person may be reached to give consent to medical treatment.
Contact #1 / Contact #2Name: / Name:
Emergency Telephone #: / Emergency Telephone #:
Relationship to Student: / Relationship to Student:
In the event such persons cannot be reached, I, the parent/guardian of ______, give my permission in case of emergency for a qualified medical doctor to administer any treatment and/or medication to my child.
Parent/Guardian’s Signature ______Date ______
Media Release Permission # 3
(Please choose one of the following options)
I, the parent/guardian of ______, give my permission to the PatersonPublicSchool District to use my child’s photo/video/audio on the district website and for other district events, promotions and related activities in any format.I hereby release the above party from liabilities arising out of what I might deem misrepresentations by virtue of distortion, optical illusions, or faulty mechanical reproductions. The publicity my child (ren) shall receive by virtue of the first such use that may be made thereof shall be full and adequate compensation for this consent.I agree all such uses of his/her name, voice, likeness, portraits, pictures, photographs, films, videotapes, audiotapes, or writings and reproductions thereof, including by not limited to tapes, plates, and negatives connected therewith are and shall remain the property of Paterson Public Schools.
Parent/Guardian’s Signature ______Date ______
--OR--
I, the undersigned parent/guardian of ______do not grant permission to the Paterson Public School District and/or its designated representative to permit my child’s picture to be taken, or likeness used on the district’s website or to be otherwise utilized by the district in regard to the district’s approved events and activities including use of name, voice, and/or writings and reproductions of the same in any form.
Parent/Guardian’s Signature ______Date ______