For allstudents from P-Kindergarten to 12th grade.
Monday, June 18 through Friday, June29, 2018
9 am through 3 pm weekdays, on the Concordia University campus
Final deadline is June 1,2018, for participation.
Both breakfast and lunch are provided free to all participants.
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer."
For additional information or for applications, contact:
Concordia University:Dr. Sally A. Baas, Co-Director, Hmong Culture and Language Prog.
(P) 651-603-6188 (FAX) 651-603-6240 (Cell) 651-238-7570
Nao Thao, M.A., Co-Director, Hmong Culture and Language Prog.(P) 651-603-6183(Cell) 651-529-7483
Registration form for grades K-12
This program will run from June 18-June 29, 2018
Today’s Date: ______/2018
Participant’s Name: ______
LastFirstMiddle Initial
Date of Birth: ______/______/______Age: ______Male ____ Female
Street Address: ______Apartment Number ______
City______State______ZIP ______
Contact: (_____)______(_____)______
Home TelephoneCellular/Other
______
How will participant be transported to and from the program?
Select the appropriate: _____ Walker _____Participant will drive ____Other
______Pick up/Drop off
I authorize the following individuals to pick up my child ______from camp.
Child’s Name
(1)______(2) ______
(3)______(4) ______
______
(For 2016-2017 School Year)
Participant’s Grade Level: ______/ District & School Attended (See below.)
A) School Dist. - (School attended 12-13) ______
______
Parent/Guardian Name: ______
LastFirstMI
Relationship to Student:______
Is Parent Address & Home Telephone the same as the student’s? _____Yes _____ No
(If different) Address ______Apt.#______
______
CityStateZip Code
Contact: Home Phone:______Cell Phone:______Work Phone: ______
EMERGENCY INFORMATION:Child’s Name: Date of Birth//
LAST FIRST M.I.
Health Insurance Provider:
Group #: Member #:
Physician’s Name Physician’s Phone ( )
Physician’s Address
CITY STATEZIP CODE
Please list/describe below any illnesses, allergies, medications or special medical needs of the student:
In case of emergency and parent/ guardian cannot be reached, please contact:
( )
EMERGENCY CONTACT NAMETELEPHONE NUMBER
RELATIONSHIP TO STUDENT(Father, Mother, Grandparent, Guardian, etc.)
I hereby give my permission for my child to participate in community performance activities related to this Hmong Language and Culture Program. *Media Permission: I understand that media (i.e. – photographs, articles, video footage, etc.) of this Hmong Language Program may include my child or myself, and I hereby give Hmong Culture and Language Program permission to use such media for public relations and promotional purposes. I hereby release Hmong Culture and Language Program from any and all claims arising out of or in connection with the use of media related to this Hmong Culture and Language program for public relations and promotional purposes, including any and all claims for libel.
□ I give permission for my child’s name to be used in media coverage□ Do not use my child’s name in media coverage.
I give permission for my child to be observed and tested as a part of measuring acquisition of Hmong/English or other language and culture.
□ I give permission for my child’s name to be observed/ assessed □ Do not observe or assess my child.
__
Parent/Legal Guardian SignatureDate Email Address