Summer Academy
2016Application forElementary AIS/RTI, ESOL and EnrichmentPrograms
Where: Groton Elementary
When: July 11,2016 – August 5, 2016
Monday-Friday8:00 am-10:00 am
Families must submit applications to their school principal by May 27th. Applications will then be forwarded to TST BOCES by June 10th. Students who meet the criteria for Summer Academy and who are approved by their school principal will be admitted to the Summer Academy program. Principals will notify families by June 8th of their acceptance.
Student Name: ______
(First) (M.I.) (Last) (DOB: MM/DD/YYYY)
Home Address: ______
(Street) (City) (Zip code)
Parent/Guardian Name(s): ______
(First) (Last) (Relationship to Student)
Parent/Guardian Name(s): ______
(First) (Last) (Relationship to Student)
Parent/Guardian Phone:______
(Home) (Cell) (Work)
Emergency Contact: ______
(Name)(Phone #)(Relationship to Student)
Emergency Contact: ______
(Name)(Phone #)(Relationship to Student)
I request Summer Academy services for my child named above. My child and I have read and agree to the code of conduct.
Parent/Guardian signature:______Date:______
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MEDICAL INFORMATION: In case of emergency, I understand that my child will be transported to the nearest medical facility and that I will be notified as soon as possible. I give my consent and authorization for any first aid medical treatment to be made including any diagnostic procedure, medical, dental, surgical care and hospitalization determined advisable by any physician, dentist or hospital personnel providing health to my child.
Please list any allergies to conditions your child has (i.e., medications, sun, food, plans, bee stings, motion sickness, etc.) ______
Please list any major illness or injury, including chronic conditions (asthma, diabetes, and seizures):
______
Please list any medications your child takes: ______
Is Transportation needed? (Circle one)YesNo
PICKUP AND DROPOFF INFORMATION: If your child needs to be picked up or dropped off at a different address (other than the address listed above), please list this information below.
PICKUP Address:______
DROPOFF Address: ______
______Home only
______Day care
______Other-please specifiy
List any other adults who have permission to pick up the student in case student is sick or in need of an appointment (please include the adult’s phone number):
______
______
Order of Protection: If the student has an order of protection, please provide a copy of the order with this application.
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Photo Consent:
Photographs may be taken during the summer program by local media. Please check belowifyoudo not want your child’s photograph or name used for any purposes.
____ I DO NOT WANT MY CHILD’S PHOTO AND/OR NAME RELEASED FOR ANY REASON
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Please return this application to your school office.
Thank you,
Maxine Parker, Supervisor of External Programs at TST BOCES
Diahann Hesler, Director of External Programs, Career & Technical Education, and Adult Education at TST BOCES
______
To be completed by sending district:
School District: ______
Student ID#: ______Student Gender: ______
Program: AIS/RTI/ESOL/Enrichment(circle one)
Does the student have an IEP? Yes/No (circle one)
Does the student have a 504 plan? Yes/No (circle one)
Recent Reading Score ______DRA/Other______
Current Teacher’s Name: ______Current Grade and School:______
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