Pathways to Success Programs explore Math
2015SUMMER Brainetics MATHEMATICS
WORKSHOPApplication Form
SUMMER BRAINETICS MATH WORKSHOP
The Summer Brainetics Math Workshop provides participants with an opportunity of practicing tricks for doing math quickly and correctly in a way that becomes second nature. In time, you're rattling off answers to math problems you never thought possible – all because you've practiced Brainetics techniques!Instruction will be done at a level to make all content approachable yet challenging for elementary-school and middle-school students. Participants should expect a very engaging and collaborative learning environment. Select ONE SESSION, 15 participants per/class
⃝ Dates: June 22nd- June 24thTime: 9 a.m. - 12 p.m.Location: ESY, LLC
⃝ Dates: July 14th-July 16th Time: 9 a.m. - 12 p.m. Location: ESY, LLC
138 Canal St. Suite 303, Pooler GA (located behind Cancun’s and Sisters Restaurants in Pooler)
Eligibility:30participants, ages 10-12years old with an interest in improving math skills.
Required:Aletter of recommendation from teacher, guidance counselor or supervisor in addition to the application form. There is a$15 registration fee(money order).
Student Information:
Name:______Age: ______Sex: □Male □Female
School ______GPA______
Email[s]: ______/ ______
Cell phone[s]: (______) ______(______) ______
Current Grade Level: □3th □4th □5th □6th
Most recent Math CRCT / MAP/RIT score:______
□exceeds standard □meets standard □does not meet standard
Parent or Guardian Information:
Name: ______Date:
Address:
City: State:Zip:
Phone:______Alternate Phone: ______
Email: ______
Consent, Release and Waiver Form
I, __, the parent and/or guardian of ______(“Mentee”), hereby give my consent for him/her to participate in the 100 Black Men of Savannah, Inc. (“Savannah 100”) youth mentoring programs. I also agree that:
- Program staff, volunteers, Collegiate 100, and members of the Savannah 100, have my permission to provide Mentee reasonable first aid and transportation to a health care facility in the event Mentee needs emergency medical attention. I agree to release any records necessary for treatment, billing, referral or insurance purposes in the event Mentee is transported to a health care facility for emergency medical attention.
- Pictures and video or audio recordings of Mentee participating in the Program are hereby released by me for use in appropriate news media (e.g. newspapers, radio, and television stations) and in the marketing materials for the Savannah 100 (e.g. website and brochure).
- In consideration of Mentee being allowed to participate in the program I agree on behalf of myself, Mentee,any other parent or guardian of Mentee, and any personal representative, agent, heir, successor or assign of the foregoing (hereinafter “Mentee’s parties”) to forever and irrevocably indemnify,hold harmless, waive liability, release and dischargeSavannah 100, 100 Black Men of America, Inc., Programstaff, and any corporate entities, officers, directors, members and employees related to any of the Programfrom any and allclaims, demands, causes of action, rights, costs and charges of whatever kind or nature, arising out of or related to any known or unknown, foreseen or unforeseen bodily or personal injury, death, or property damage, resulting from Mentee’s voluntary participation in Program.
- In consideration of Mentee being allowed to participate in the Program, I covenant and agree on behalf of Mentee’s parties that Mentee’s parties will not sue Program parties for any claims for damages arising from or related to Mentee’s voluntary participation in Program.
- Assumption of Risks: Engagement in Athletic Activities carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries and that participation in any physical activity involves peculiar risks that even when safety precautions are utilized, injuries can occur. I also understand that if I experience pain or physical discomfort during these activities I will decrease or stop participating. I am aware that personal health/accident insurance is my sole responsibility. I affirm that to the best of my knowledge, I do not have any medical condition or physical disability that will preclude my safe participation.
- I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in The Engagement of Athletic Activities and participation in attendant activities. I hereby assert that I knowingly assume all such risks.
I hereby acknowledge that I have read this form and agree to waive certain legal rights by signing this Consent, Release and Waiver.
BY: Date: ______
PARENT/GUARDIAN
scholarship section
Household Information
Household Size: □-1 □-2 □-3 □-4 □-5 □-6 □-7 □-8 □-Other ______[please specify]
Total Household Annual Income $ ______
Proof of Income: ______(W4s; Pay-Stubs; Award Letters; etc.)
Who is financially responsible for the child’s tuition? ______
In order to qualify for a private scholarship for the $15.00 participation fee, you must have an annual household income (before taxes) that is at or below the following amounts:
Household Size* / Maximum Income Level(Per Year) / Your Family
(Check One)
1 / $15,171
2 / $20,449
3 / $25,727
4 / $31,005
5 / $36,283
6 / $41,561
7 / $46,839
8 / $52,117
*For households with more than eight people, add $5,278 per additional person.
Please complete the application and return an email scan to or a mail copy to before May 29th2015:
Pathways to Success Programs/ Math Camp
ATTN: Mrs. Q. Joyner
P.O. Box 14606
Savannah, GA 31416