Summer Academy Application
Sponsored by West Indian Foundation in Collaboration with Hartford Public Schools
July 10, 2017 – August 12, 2017
7:30 a.m – 3:00 p.m, Breakfast and Lunch included
Grades Pre-K– 12 grades
Scholar Name______Date of Birth______
Present Grade (June 2017)______School Attending______
Name of Parent/Guardian______
Address/Town______
Home Phone______Cell Phone______Wk Phone______
Emergency Contact Name______Relationship______
Address:______Home Phone______Cell Phone______
Emergency Contact Name______Relationship______
Address:______Home Phone______Cell Phone______
Is your child a walker or pick-up?
Pick-Up Name Phone Number Relationship
Pick-Up Name Phone Number Relationship
Has your child ever attended the West Indian Summer Academy? Yes___or No__
Location of Summer Academy: Martin Luther King Jr. Elementary School, 25 Ridgefield Street, Hartford, CT 06112
Summer Academy Director: Mrs. Joyce Bennett @ (860)
Registration Fee $20.00
Photo Release
I hereby agree that all photographs, negatives, prints, paintings, drawings, sketches, reproductions and likeliness of any kind made of the child are and shall remain the property of the West Indian Foundation. I give my permission that said works may be published, displayed, reproduced and circulated in any form by West Indian Foundation with or without the child’s name for commercial purposes or otherwise, including advertisement in any media and with or without any testimonial copy or other form of advertising or display. Initials:
Parental Release Form
I, the parent/guardian of the minor child listed on this application, for ourselves, our heirs, executors and administrators hereby release, waive, acquit and forever discharge The West Indian Foundation, Hartford Public Schools, their representatives, successors, insures, assigns or any other person or entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, demands or causes of action for any and all loss, participation in activities of said organizations either at or away from the Program. I understand that The West Indian Foundation is not responsible for lost or stolen items. Initials:
Mandatory
It is mandatory that all WIF summer Academy scholars participate in the West Indian Parade on August 12, 2017. I have read and affirmed that all information is correct and truthful on this application. Initial:
Scholar Name:
Medical Treatment
If in the event that I cannot be reached in emergency, I hereby give permission to the physician, Connecticut Children’s Medical Center, and or St. Francis Hospital selected by MLK Nurse/The West Indian Foundation to hospitalize, secure proper treatments for, to order injection, anesthesia, surgery for my child as named herein. In the event that my child, as named herein, should require basic first aid and/or minor treatments, as ordered by school/program staff, I give permission for the health care professional to administer such aid or treatment for my child.
Student Medical Information (please print)
Medical Conditions:______
Allergies______
Food Allergies______
Epi Pen Yes______No______
Asthma Yes______No______
Physician Information
Physician:______
Physician Phone:______
Hospital:______
Field Trip Permission
PARENTS/GUARDIANS WHO ARE NOT SENDING THEIR CHILD/REN ON FIELD TRIPS MUST KEEP THEIR CHILD/REN AT HOME OR MAKE OTHER ARRANGEMENTS FOR THE DAY. THE WEST INDIAN FOUNDATION MAKES NO PROVISION AT THE SCHOOL FOR STUDNETS WHO DO NOT GO ON THE FIELD TRIPS.
Initial:
Technology
I understand that The West Indian Foundation will take all necessary and reasonable precautions to ensure that my child will not have access toinappropriate materials on the Internet. I further understand that not only will The West Indian Foundation discuss Internet safety with my child but that I, as the parent/guardian, must discuss this with my child as well. Initial:
Dismissal
I understand that The West Indian Foundation will take all necessary steps to dismiss on time.In the unlikely event that participants will be dismissed late all parents/ guardians will be notified in a timely manner.
Initial:
I have read the completed application and this form, I understand the rules of The West Indian Foundation Summer Academy and request that my child be admitted into the program.
______Date:______
Parent or Guardian Signature
INTERESTED
IN
CRICKET????
Monday thru Friday
3:00pm-5:00pm
JULY 10, 2017- August 11, 2017
Name______Date of Birth______
Present Grade (June 2017)______School Attending______
Name of Parent/Guardian______
Address/Town______
Home Phone______Cell Phone______Wk Phone______
Emergency Contact Name______Relationship______
Address:______Home Phone______Cell Phone______
Emergency Contact Name______Relationship______
Address:______Home Phone______Cell Phone______
Is your child a walker or pick-up?
Pick-Up Name Phone Number Relationship
Pick-Up Name Phone Number Relationship
Location: Keney Park Cricket Field