2017 STREAM Express Summer Camp and 2017 HCA Summer Drama Camp
I AM REGISTERING FOR: ___2017 STREAM Express Summer Camp ___2017 HCA Summer Drama Camp
The 2017 STREAM Express Summer and Drama camps will both be located at St. Michael School
Child’sinformation:
Child’sNamePhone
Address_CityStateZIP BirthDate:______Age:___EnteringGrade:___(K-6 for STREAM) ___ (2-8 for DRAMA)
Name ofSchoolPhone_
Parents’information:
Parent’sNamePhone Address Phone City State ______ZIP Email Parent’sName Phone Address Phone City _ State_____ ZIP Email
Emergency contact person’sinformation:
EmergencyContact_Phone Relationship toChild_ _ _Phone
EmergencyContact_Phone Relationship toChild_ _Phone
Persons permitted to pick up yourchild*:
Name__RelationshipPhone Name _ _ Relationship __ Phone
Name__ Relationship __Phone
*Persons responsible for pick up should be prepared to showidentification.
T-shirt information
Size(circleone):XS (2 –4)S (6 –8)M (10-12)L (14–16)ASAMAL XXL
2017 STREAM Express Summer Camp and 2017 HCA Summer Drama Camp
PaymentSchedule
Child’sNameGrade level for 2017 –18 Parent’sName Email
Phone
______I would like to sign up for the FREE Early Arrival program. Early Arrival begins at 8:00am. Space is limited.
Early Arrival (FREE) and after camp Latchkey (ADDITIONAL FEE) programs are available to participants in the STREAM and DRAMA camps.
Please fill out the calendar below by checking the boxes for the camps and weeks your child willattend:
6/5–6/9 / 6/12–
6/16 / 6/19–
6/23 / 6/26-
6/30 / 7/3–
7/7 / 7/10–
7/14 / 7/17-
7/21 / 7/24–
7/28 / 7/31–
8/4 / 8/7–
8/11 / 8/14–
8/18 / Total
Fees
STREAM Camp
$130 /Wk
HCA students
STREAM Camp
$160/Wk
Non-HCA
Students / No camp 7/4
No camp 7/4
DRAMA Camp $250 for HCA students / / Express
Camp
Drama / Express
Camp
Drama
/ Express
Camp
Drama
ends 8/16
DRAMA Camp $275 for Non-HCA Students / Express
Camp
Drama / Express
Camp
Drama / Express
Camp
Drama ends 8/16
Totalfees Here: / ____
Total here
Ifyourchildmissesa day,wecannotrefund partialpayment.AllstudentsmustattendallSTREAMExpressfield trips.
Payment Options (ChooseOne)
1In Full: I have enclosed check#for the full amountof.
2Monthly: I have enclosed check#for June in the amountof(1/3 of thetotal)
Two additional payments of 1/3 the total are due by July 1stand August 1stto Holy Cross Academy, 219 EastMaple Street, Suite 205 North Canton, Ohio 4472. Payments must be received by the 1stof each month to holdyour registration. ** Returned checks will result in a cancelledregistration.
3 By Credit Card for the full amountof.
Checkone:MasterCardVISADiscoverAmericanExpress Issuing BankName
Name onCard
Account#ExpirationDateSecurityCode_____
2017 STREAM Express Summer Camp and 2017 HCA Summer Drama Camp
BEHAVIOR POLICY
Holy Cross Academy follows the policy guidelines set forth by the Diocese of Youngstown Student Code of Conduct. This code states that our programs have a special responsibility for the conduct of children and for ensuring the rights of leaders to interact with children in a safe and caring Christian environment.
Holy Cross Academy would like your child to have the best experience possible. Thus, all participants must understand and follow these guidelines and rules.
These rules and expectations are in place to ensure the safety of your child and staff:
Listen to staff. Respect staff and other participants.
Respect facility property.
Keep hands, feet, and other objects to yourself. Participate in workshop activities. Use an inside voice when indoors.
Follow staff instructions.
Clean up after yourself.
Be positive and have fun!
Should a participant choose not to follow any of these rules, these are the guidelines that the staff will follow to handle the situation:
Step 1: Verbal warning. Step 2: Time out / suspended from activity participation for an age-appropriate time. Step 3: Behavior warning report sent home. Step 4: Conference with parent. Step 5: Meeting with the supervisor, necessary staff, parent(s), and child.
In the event that a participant engages in behavior which poses a threat of bodily harm to himself, others, or facility property, an immediate meeting will be held with the parent(s), or guardian. Continued behavior infractions may result in a child not being permitted to continue.
The staff will review these rules with your child at the beginning of the workshop. Thank you in advance for your cooperation, and we hope to have a great experience!
I have reviewed the discipline policy with my child and agree to abide by the rules and expectations set forth:
Parents Signature:______Date:______
Child’s Signature:______Date:______
2017 STREAM Express Summer Camp and 2017 HCA Summer Drama Camp
Permission to Publish Consent Form
PHOTO/VISUAL CONSENT
_____ I give permission for my son/daughter to be photographed or videotaped at the workshop and production(s). I realize that the photo or video may be published in the newspaper, magazine, HCA social media pages, HCA website, or other publication deemed appropriate by HCA for informational or educational purposes regarding its programs.
OR
_____ I have read the Photo/Visual Consent and do NOT give permission for my child to the above request.
PERMISSION TO PUBLISH ON THE INTERNET
_____ I give Holy Cross Academy the right to use the following student material for my son or daughter for inclusion on the internet on the Holy Cross Catholic Schools Websites, digital advertising and social media pages. I affirm that I have the legal right to issue such consent.
Check ALL that apply.(A blank space indicates the intent of the parent or guardian to NOT allow that information on the HCA Website.)
_____ first name only_____ student work
_____ group photograph _____individual student photograph
DIRECTORY INFORMATION
In compliance with FERPA (Family Educational Rights and Privacy Act), this Holy Cross Academy considers the following to be FERPA Directory Information: Child/student’s name, student’s parent(s) or guardian(s) name(s), addresses, phone numbers, dates of attendance, and pictures taken of the student participating in activities. This directory information may be released without prior consent of the holder of FERPA rights. Nonetheless, the HCA will withhold such information upon written request to the school office of the parents, except where other state or federal law may require disclosure to legitimate authorities.
Check one:
_____ I give my permission for HCA to release the above directory information in news releases to outside publications (ex. local newspapers).
_____ I DO NOT give my permission for HCA to release the above directory information in news releases to outside publications (ex. local newspapers).
2017 STREAM Express Summer Camp and 2017 HCA Summer Drama Camp
Emergency Medical Authorization
Student: ______Grade in 2016 - 17: ______
Address: ______Home Phone: ______
Mothers’ Name: ______Cell Phone: ______Other Phone: ______
Email:______Email:______
Fathers’ Name: ______Cell Phone: ______Other Phone: ______
Email: ______Email: ______
Alternate Persons to Contact: (People to contact if your child is ill and neither parent can be reached.)
Name: ______Relation: ______Cell Phone: ______
Other Phone: ______
Name: ______Relation: ______Cell Phone: ______
Other Phone:______
Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairments or medical condition which the school or an emergency physician should know. ____________
______
Medications are to be placed inside a plastic zip lock bag labeled with your child’s name and be brought to the office by parents. Children are NEVER to transport medications. All medications, including prescription AND OTC meds MUST be accompanied by a physician’s signed orders and include dose instructions. NO EXCEPTIONS. OTC medications include aspirin, Tylenol, cough drops, etc. If your child requires an inhaler, please request a form.
Purpose: To enable parents or guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority when parents or guardians cannot be reached.
I hereby give consent for the following medical care providers and local hospital to be called:
Doctor______Daytime Phone______
Dentist______Daytime Phone______
Medical Specialist______Daytime Phone______
Local Hospital______
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctor, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible.
This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.
Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted:
______
Signature______Date______
************************************************************************************************************
Refusal to Consent
I do NOT GIVE my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following action: ______
______
Signature______Date______
2017 STREAM Express Summer Camp and 2017 HCA Summer Drama Camp
INFORMATION: LEGAL CUSTODY
Date: ______
Child’s Name: ______Grade:______
Address of Child’s Residence: ______
______
Child lives with: _____ both natural parents
_____ natural mother, step adoptive father
_____ natural father, step/ adoptive mother
_____ only mother
_____ only father
_____ grandparents (with legal custody)
_____ other relative or guardian (with legal custody) Relationship: ______
_____ Other: Please explain. Include any arrangements that the school will need for its information and records
______
______
------
Yes / No (please circle) Is there a court order (or pending order) affecting the custody and/or residency of the child?
If yes, please fill in section below.
Residential Parent/ Guardian: Name: ______
Address: ______
City/ Zip: ______
Phone: ______
Please attach a certified copy of the page of the court decision bearing the case number and those sections referring to visitation rights and contacts with the school. Also include the page bearing the judge’s signature and court seal. This copy should include any and all modifications made as of the date of registration of the child in this school. it is also the responsibility of the parents to inform the principal of any subsequent modifications during the child’s tenure at the school.
Non-residential parent: Name: ______
Address: ______
City, Zip: ______
Phone: ______
Please circle:
Yes / No Does the non-residential parent have visitation rights?
Yes / No Is there a court decision that states that the non-residential parent should NOT receive school
information or attend school activities?
Yes / No Is the non-residential parent responsible for paying tuition?
Signature of person completing the form: ______
It is the parent’s responsibility to be sure that the HCA has the most up-to-date information.