Summer Blast 2015 Application Form

Enrichment, Field Trips and Fun for Teens in Grades 7-10

Monday June 29, 2015 – Friday August 7, 2015

In order to be eligible for participation in the Summer Blast Program, this application must be completed in full and signed by the participant and a parent/guardian. Applications may be dropped off, mailed, faxed or emailed to:

Ms. Kathy Mucha, Admissions Coordinator, by Friday, June 5, 2015.

CREC Polaris Center

474 School St, East Hartford, CT 06108

Fax: 860-289-8380 Email:

Applications submitted after the deadline will be considered

on a space-available basis.

NEATLY Print All Required Information/Name & Full Address Must Be Clear

Name: ______Date of Birth ______

School District: ______Home School ______

Grade (this past year): ______

Full Address: ______Zip Code:______

Cell Phone: ______Home Phone: ______

Medication needed during program?: (Ex. inhaler, epi-pen, PRN or prescription meds; Time?)

______

Known allergies: ______

Physician: ______Phone: ______

Medical Insurance Provider: ______Policy Number: ______

Hospital Preference: ______

Permissions, Participation Requirements and Statement of Understanding

Sessions run Monday through Friday, 8:30am to 2:30pm, closed Friday July 3rd.

Breakfast, lunch and snacks are included. Admissions costs are included for all field trips and activities.

Students should arrive at Polaris no earlier than 8:15 a.m.

Participants need to wear clothing and footwear appropriate to the activities planned for each day. Extra clothing including rain gear may be necessary depending on weather conditions.

The Summer Blast Program may involve outdoor activities that could be vigorous, requiring normal good health. Participants need to be cooperative and responsible at all times to help ensure a safe and enjoyable environment for all.

Access to emergency communication will be provided through staff cell phones and two-way radios. Simple first aid kits will be available on all trips off campus.

I understand and agree to the above requirements. This permission slip also authorizes a licensed physician or other medical staff to carry out emergency medical care deemed necessary for my child if I cannot be reached.

Participant Signature: ______Date: ______

Parent / Guardian Signature: ______Date: ______

Cost:

$130.00 per week

Please indicate your preferred session dates by placing a check mark next to the dates you’d like to attend:

_____ June 29 - July 2 _____ July 6 – 10 _____ July 13 - 17

_____ July 20 - 24 _____ Jul 27 – 31 _____ August 3 - 7

Applications due by Friday June 5, 2015

Payments may be made by Cash, Credit Card (MC or Visa accepted)

or bank check/ money order, payable to: CREC POLARIS CENTER.

Once the application and payment have been processed, we will confirm your child’s enrollment. Standard permission forms and a copy of immunization record & last physical exam will be required prior to the first day of attendance.

A brief orientation visit to our location prior to attendance is required, so that students and families are familiar with where their child will be coming, we can finalize all paperwork/payment and set the stage for a great summer experience!

Payment is required prior to each week a child attends.

Please feel free to call with any questions,

we’d be happy to assist you!

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2015 Summer Programs Standard Permissions

Child’s Last Name First Name / Date of birth

Child lives with: □ Mother □ Father □ Both Parents

□ Other/Guardian(please specify): ______

Parent/Guardian Name: ______

Address: ______

Home Phone: ______ Cell Phone: ______

Work Phone: ______

Email (optional) ______

If your child needs to go home early, who do you prefer we notify first?

□ Mother □ Father □ Other/Guardian (please specify): ______

At what phone number? ______

For other non-urgent matters, how do you prefer we contact you?

□ Cell □ Work □ Home □ Send note home

□ Other (please specify): ______

In case of an emergency, illness or other reason and parent/guardian cannot be reached, please list the names of up to three (3) persons to call whom you authorize to transport and assume responsibility of your child.

Name / Relationship / Phone Number with area code
1
2
3

Student Health History

Please circle Y if “yes” or N if “no.” Explain all “yes” answers in box provided on next page.

Any health concerns Y N / Hospitalization or E. Room visit Y N / Concussion Y N
Allergies to food or bee stings Y N / Broken bones or dislocations Y N / Fainting or blacking out Y N
Allergies to medication Y N / Any muscle or joint injuries Y N / Chest pain Y N
Any other allergies Y N / Any neck or back injuries Y N / Heart problems Y N
Any daily medications Y N / Problems running Y N / High blood pressure Y N
Any problems with vision Y N / “Mono” (past 1 year) Y N / Bleeding more than expected Y N
Uses contacts or glasses Y N / Has only 1 kidney or testicle Y N / Problems breathing/coughing Y N
Any problems hearing Y N / Excessive weight gain/loss Y N / Any smoking Y N
Any problems with speech Y N / Dental braces, caps, or bridges Y N / Asthma treatment (past 3 yrs) Y N
Diabetes Y N / ADHD/ADD Y N / Seizure treatment (past 2 yrs) Y N

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Child’s Last Name First Name / Date of birth
Any YES answers from Student Health History above, explain:
Hospital Preference:
Standard Permissions:
The school nurse has permission to share health information with staff members for health and safety purposes? / YES / NO
Will your child require prescription medication during program hours? / YES / NO
Name(s) of medication and time required:
If Yes, we’ll need a supply of medication(s) AND a Medical Authorization Form from a doctor or nurse practitioner. Students may carry some medications, per program RN and CREC Health Services guidelines. Contact the nurse’s office at (860) 289-8131 x3430 with any questions.
Please circle whether or not you give permission for your child to have:
Tylenol (Acetaminophen) for fever, headache, menstrual cramps, bone or muscle pain, or dental pain, according to our standing physician’s orders? / YES / NO
Ibuprofin for menstrual cramps or muscle pain? / YES / NO
“Off” Skintastic Bug Spray, if requested/as necessary? / YES / NO

______/_____/_____

Print Parent/Guardian Name Date

______

Signature Parent/Guardian

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474 School Street, East Hartford, CT 06108 860-289-8131  