SCPS 21STCentury Community Learning Center
Hamilton Elementary School
Summer Programming Application 2018
STUDENT INFORMATION (Legal Name)
Name: ______CurrentGrade:______DOB: ______
Home Address:______City:______Zip Code:______
PARENT/GUARDIAN INFORMATION
Mother: ______Home Phone:______
Work Phone:______Cell Phone:______Email address:______
Father: ______Home Phone:______
Work Phone:______Cell Phone:______Email address:______
Student lives with (check all that apply): Both Parents Mother Only Father Only
Parent & Step Parent Grandparent(s) Other ______
TRANSPORTATION
My child will be:
Walker ___ Front ___ Back
Car Rider
Please list people authorized to transport your child to and from the Hamilton’s Summer Program. If your child’s method of transportation should change, the program staff must be notified by a parent or guardianIN WRITING.
My child(ren) can be picked up by the following people:
Name:______Phone:______Relationship to student:______
Name:______Phone:______Relationship to student:______
EMERGENCY CONTACTS
In the event the parents/guardians cannot be reached, a 21stCCLC staffmember will contact the people listed below:
Name:______Phone:______Relationship to student:______
Name:______Phone:______Relationship to student:______
Please list any additional people you authorize to pick up your child(ren) from the after school program. A picture identification will be required upon arrival.No student will be released to any personnot listed on this registration form.
Name:______Phone:______Relationship to student:______
Name:______Phone:______Relationship to student:______
MEDICAL INFORMATION
Please list any medical conditions/allergies that apply to your child.______
______
Medication(s) taken by student:______
Physician Name:______Physician Phone Number:______
Preferred Hospital in case of emergency: ______
PHOTO PERMISSION FORM (Please check one of the following)
___I give permission for my child(ren) to be photographed/videotaped with respect to SCPS/21st CCLC activities and events.
___I do not give permission for my child(ren) to be photographed/videotaped with respect toSCPS/21st CCLC activities and events.
PROGRAM PERMISSIONS (Please initial next to each)
______FIELDTRIPS:As part of an educational experience or activity, under the supervision of the SCPS/21st CCLC staff, my child(ren) is granted permission to participate in program related fieldtrips.
______MOVIE RATING PERMISSION:As part of an educational experience or activity, under the supervision of the SCPS/21st CCLC staff, my child(ren) is granted permission to view presentations and or movies that have a G or PG rating.
______PROGRAM COMMITMENT:I commit to sending my child for the full program dates of Mondays-Thursdays, June 4, 5, 6, 7, 11, 12, 13, 14, 18, 19, 20, 21, 22, 25, 26, 27, 28 from 8am-2pm. If you are aware of multiple days that you are unable to send your child, please do not take up a seat from a student that can benefit from the entire program.
NETWORK ACCESS AGREEMENT:
As a condition of being granted access to the Internet through the computer network system maintained, operated, and supervised by the School Board of Seminole County, Florida, I agree to comply with the following terms and conditions. By this agreement, access is only permitted from the SCPS/21st CCLC Grant Sites.
- I understand that my child has no privacy regarding his/her use of the network access, any material found, detected, or stored on any computer used by my child to access the SCPS network or any material viewed by my child.
- I understand that my child’s activities will be monitored.
- I understand that if my child violates this agreement thathis/her Seminole County School Board network accessmay be immediately terminated. The violation may be reported to law enforcement, as appropriate.
I have reviewed and understand the information provided above. I give my consent and acknowledgement by signing below. With my signature I approve and consent to items stated above.
______
Signature of Parent/GuardianDate
Revised 4/02/18