Urban League of Metropolitan Seattle 105 14th Avenue, Seattle, WA 98122
206-461-3795 ext 3019
Please return the completed application & deposit to
Urban League of Metropolitan Seattle 105 14th Avenue • Seattle, WA 98122
Income Categories
Instructions: Find the column for the number of people in your household. Go down that column until you find the income range for your annual gross income last year. Look to the left to see what that row is labeled. That is your income category.
Household
Category
/ 1
Person / 2
Persons / 3
Persons / 4
Persons / 5
Persons / 6
Persons / 7
Persons / 8
Persons
Very Low Income
(30% of Median Income) / □
Up
to
$16,350 / □
Up
to
$18,700 / □
Up
to
$21,050 / □
Up
to
$23,350 / □
Up
to
$25,250 / □
Up
to
$27,100 / □
Up
to
$29,000 / □
Up
to
$30,850
Low Income
(50% of Median Income) / □
$16,351
to
$27,250 / □
$18,701
to
$31,150 / □
$21,051
to
$35,050 / □
$23,351
to
$38,950 / □
$25,251
to
$42,050 / □
$27,101
to
$45,200 / □
$29,001
to
$48,300 / □
$30,851
to
$51,400
Moderate Income
(80% of Median Income) / □
$27,251
to
$41,700 / □
$31,151
to
$47,700 / □
$35,051
to
$53,650 / □
$38,951
to
$59,600 / □
$42,051
to
$64,350 / □
$45,201
to
$69,150 / □
$48,301
to
$73,900 / □
$51,401
to
$78,650
Above Moderate / □
$41,701
or
More / □
$47,701
or
More / □
$53,651
or
More / □
$59,601
or
More / □
$64,351
or
More / □
$69,151
or
More / □
$73,901
or
More / □
$78,651
or
More
ULMS Children’s Summer University
PERMISSION
1) MEDICAL RELEASE: In authorizing my child/children’s participation in the Urban League of Metropolitan Seattle Summer University. I understand that I am not requesting any reasonable accommodations for my child/children due to disability and I am releasing the ULMS and its personnel from any liability due to injuries that my child/children may sustain on/off the premises while participating in this program
2) PHOTOGRAPHY RELEASE: I give permission for the Urban League of Metropolitan Seattle Summer University to use, without limitation or obligation, photographs, film footage or tape recordings which may include my child’s image or voice for purposes of promoting or interpreting the Urban League of Metropolitan Seattle Summer University.
3) INFORMATION RELEASE: I give permission for the Urban League of Metropolitan Seattle’s Summer University to share and receive information about my child/children with any school personnel regarding my child/children’s welfare. Any requests to provide information to non-school personnel must be submitted in writing to ULMS and only by those designated to receive such information. The information is limited to payment history and/or academic/social reports on participation in our programs.
4) FIELD TRIPS: I give my permission for the Urban League of Metropolitan Seattle Summer University to transport my child/children to and from field trip activities at various recreational facilities. I am also aware that fees maybe required.
Your signature below is your agreement to all the above stated permission request!
PARENT/GUARDIAN SIGNATURE DATE
Tell us about your child!
We are interested in knowing about your children prior to the start of Summer University.
Please have them answer the following:
1. Tell us about your child/ children strengths:
______
2. Tell us about your child/ children’s challenges:
______
3. Has your child EVER been suspended or expelled from school? Yes No
If YES, please explain why and how many times.
______
______
______
______
______
4. Special skills & talents:
______
5. Favorite Subject(s):
______
______
URBAN LEAGUE of METROPOLITAN SEATTLE
Children’s Summer University
Payment Contract
ULMS is a non-profit organization, offering an innovative creative learning environment.
Tuition/Fee for Urban League of Metropolitan Seattle Children’s Summer University 2010 is as follows:
Tuition is $600.00
(Unless Early Registration deadline is met!)
Upon registration, complete an Enrollment Form, return form and non-refundable deposit of $200.00 by April 5th, 2010 to Urban League of Metropolitan Seattle Education Department.
Early Registration tuition fee is $500.00: if non-refundable payment of $200.00 is received by
Monday, April 5th, 2010
No invoices will be sent!! Our goal is to remain as flexible as possible in supporting the educational needs of the youth we serve. If you have any questions regarding your financial plan contact Darah Harris-Everhart at 206-461-3792 e 3019 or
I, ______, acknowledge that I have read and agree to the above statements in regards to my child/children’s account with the ULMS Children’s Summer University, and will comply with all of them. In the event that I am unable to fulfill any/all commitments stated, I will contact the ULMS Education Office Manager.
I agree to pay tuition of $______& my remaining balance of $______by June 25th, 2010 in order for participation in Summer University.
Parent Name (signature) Date: ______
ULMS Education Director: Date:
ULMS Children’s Summer University
Pick-up Authorization
Please indicate below person(s) other than yourself, who will be authorized to pick-up your child/children.
NAME RELATIONSHIP PHONE#
______
______
Medical Information
Child NamePhysician Name Phone# ( )
Name of Hospital/Clinic
Child Name
Physician Name Phone# ( )
Name of Hospital/Clinic
If you cannot be reached in case of emergency, we will contact the person you have listed for your emergency contact. If we are unable to reach that person, the paramedics will be called if needed!!
Please answer the following questions:
Do your child/children have any allergies?
Yes No
If yes, please explain.
Have your child/children been under a physician’s care for any chronic or recurring illness?
Yes No
If yes, please explain.
Do your child/children have any known physical, mental, or social difficulties which may affect their performance in our program?
Yes No
If yes, please explain.
Are there any activities that your child/children should be restricted from due to an illness?
Yes No
If yes, please explain.
Is your child/children on medication?
Yes No
If yes, please explain and see the Education Director with complete details.
We can only give children medication, if we have legal documented information signed by a physician, stating what its use is for, type of medication and specific dosage. Also, the medication must be labeled with current medical information (child’s name, expiration date, dosage, etc.) as well as its original container!
Urban League of Metropolitan Seattle
Children’s Summer University Participant Contract
Summer University provides a great opportunity to have fun, meet new friends, and be creative. We are glad that you are a part of this program! In order for everyone to have the best possible experience, it's important for us to be respectful of others and to follow some basic rules. By reading and signing this contract you're helping make sure that you and your fellow participants will have the best time possible.
I will work cooperatively and respectfully listen to and follow the instructions of the SU staff, teachers, and volunteers.
I will follow the directions and safety rules of my van driver.
I will treat the other Summer University students with respect and dignity, and will not use unkind words or actions toward any participant.
I will stay within the physical boundaries of Summer U classrooms and break areas.
I will obey all rules to stay away from the water and I will not throw anything in the water.
I will respect and help maintain Summer U and University of Washington facilities including its classrooms, vans, and other property.
I will conduct myself with a positive attitude, showing respect for others and myself by not being disruptive, hostile verbally, or physically abusive.
Consequences for students who break this contract:
First Time: Removal from class and remain in the SU office for the day.
Second Time: Above, plus meeting with parent/guardian before you can return to SU.
Third Time: Dismissal from program. Parent/guardian will be called to pick up student. (Parents will not be reimbursed for any time remaining.)
I understand that I may be suspended from Summer U for a period of time to be determined by staff for fighting, destruction of property, endangering myself or others, disregarding water safety rules, or other inappropriate behavior not listed in this contract.
I understand that I will be immediately expelled for bringing drugs, alcohol, and dangerous weapons or by committing theft, vandalism, violence, or for smoking.
I agree to follow this contract so I and everyone else may enjoy Summer U.
Student______Date______
Parent/Guardian ______Date______
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