Kennedy King College-Minority Science and Engineering Improvement Program 2013
|
|
- Percival Potter
- 5 years ago
- Views:
Transcription
1 Dear Student & Parent/Guardian: This is the Application Packet for the Minority Science and Engineering Improvement Program at Kennedy King College. All documents within this packet must be completed and signed. In addition, we ask that you take the time to write neatly and clearly. Thank you, Martin O. Pieters Print Student s Name: Forms: Completed 1. Registration Form Protocol Interview Parent Consent for Authorization for Medical Attention and Release From Liability Photo Release form... Page 1
2 Form #1 STUDENT S NAME: REGISTRATION FORM Academic Year SCHOOL: GRADE: DIV: STUDENT ID#: SEX: Male Female BIRTH DATE: STUDENT S FATHER/GUARDIAN S NAME: FATHER/GUARDIAN S MOTHER/GUARDIAN S NAME: MOTHER/GUARDIAN S FATHER/GUARDIAN S CELL PHONE #: MOTHER/GUARDIAN S CELL PHONE #: The address provided below: (Is this a change of address yes ADDRESS: no for our files?) CITY: STATE: ZIP CODE: HOME PHONE #: PARENT S WORK #: PARENTS PLACE OF EMPLOYMENT: FATHER/GUARDIAN: EMERGENCY CONTACT INFORMATION NAME: PHONE #: NAME: PHONE #: PARENT/GUARDIAN S SIGNATURE: MOTHER/GUARDIAN: COMMENTS: PARENTS, DO NOT WRITE BELOW THIS LINE SIGNATURE: DATE: Page 2
3 Form #2 PROTOCOL PRINT STUDENT S NAME: ATTENDANCE Eighty percent attendance in the Program is required of each participant this includes but is not limited to: Classes, Enrichments, and Workshops. Parents must call the main office if students will be absent. Students must call the main office if they are going to be tardy/late. Students will not be dismissed early from the Program without a telephone call and written notification from the student s parents. Parents are required to send written notification to the Program Director for students who have scheduled a planned absence for more than two consecutive days. This written notification must include the dates that students will not be in attendance. Parents are required to provide MSEIP staff written notification of any medical conditions their student may have. Students who are absent for medical reasons will not be permitted to participate in program activities without a written medical release from their physician. Students will not enter any Kennedy King College facility, including but not limited to (Coffee Shops, Bookstores, etc.) without prior permission from MSIEP staff. ATTIRE/WEAR APPAREL We strongly encourage students not to carry large sums of money, wear expensive jewelry or carry electronic equipment that will attract unwarranted attention, especially if they are traveling by public transportation to and from the campus. It is important that students dress appropriately for MSEIP classes and activities. Classrooms are air conditioned during the summer and may be cool in the winter months because of the proximity of classrooms to entryways. Students should layer their clothes so that they can add or remove items as needed to accommodate temperature changes. The wearing of hats, caps and other head coverings in doors is not permitted, except for students who wear caps or other head coverings because of their religious beliefs or for medical or health reasons. Pants must be worn at a level that will not expose the student s undergarments or anatomy. Skirts and shorts must be worn at a level that is no more than 2 above the knee. Students cannot wear garments that will expose their bare midriffs. When students are engaged in sports activities shorts must be worn at a length that is no shorter than mid-thigh. Male students are strongly encouraged not to wear earrings. Students must wear the MSEIP T-shirt at all times when they are attending an off-campus MSEIP sponsored activity. USE OF ELECTRONIC EQUIPMENT/ACCESS TO CELL PHONES Students cannot use cell phones, radios, headphones, CD players, computer games, and personal electronic devices during their participation in any MSEIP sponsored classes and activities. Parent who need to contact their student are strongly encouraged to call the main office. Students may also contact MSEIP staff to make emergency phone calls at anytime they are involved in MSEIP activities or classes. Cell phone must be kept in the off mode while students are on campus or participating in MSEIP activities. ENRICHMENTS Students are required to attend one enrichment per quarter. We ask that your child not use cell phones or bring: radios, headphones, CD players, computer games, personal electronic devices or large amounts of money to any Program enrichment. If you need to contact your child, our staff is equipped with phones for emergency use only. Violations of disciplinary infractions as it relates to this protocol could disallow your participation in any enrichment. Page 3
4 TUTORIALS Students are expected to arrive least minutes prior to their scheduled time and come prepared to complete assignments. Students are expected to communicate and cooperate with tutors on all assignments. Students will be required to bring a daily planner and all other assigned materials and text books with them each time they participate in academic classes or workshops. BEHAVIOR EXPECTATIONS $ Students must be prepared to fully participate in all academic activities. Each session, students must bring notebooks, writing utensils, textbooks and completed homework. $ Students should be attentive to, courteous, and responsive to program staff and student leaders during any MSEIP sponsored activities. $ Students misconduct will be handled as follows: First Notice: Written notice will be forwarded to parents providing details of the student s inappropriate behavior. Second Notice: Third Notice: If a second written notice of student misconduct is needed, it may result in a suspension from the program. Students who receive a third notice of misconduct will be dismissed from the program. PARENT EXPECTATIONS/PARTICIPATION $ Parents agree to pick-up their student on time. Parents who are not able to do this must make other arrangements prior to the designated pick-up time. $ Parents agree to provide MSEIP staff with emergency contact information and the names of other people who are approved to pick up their students from the Program. $ Parents are required to come into the building to pick-up and sign-out their student after dark. $ Parents are required to schedule biannual interviews with MSEIP staff to discuss their child=s academic progress. $ Parents agree to support the Program s academic goals and protocol. $ Parents are expected to provide MSEIP with valid and operating emergency phone numbers. TIMELY SUBMISSION OF ACADEMIC DOCUMENTS $ Students are required to submit Grade Reports for every grading period. Parent s/guardian s Signature: Parent s/guardian s Signature: Student s Signature: Staff s Signature: Date: Date: Date: Date: Page 4
5 INTERVIEW Form #3 NAME: SCHOOL: GRADE: ADDRESS/APT. #: CITY, STATE: ZIP CODE: HOME PHONE#: GENDER: MALE FEMALE AGE: Program: MSEIP Project 1. What do you expect to gain from your participation in this program? (Check all that apply.) improvement in math skills improvement in reading skills improvement in writing skills leadership training college opportunities career opportunities better understanding of others participation in activities and events educational resources in Chicago learn more about your self 2. Indicate the subject areas that interest you most: a. b. c. d. 3. Indicate the areas where you need special attention: a. b. c. d. 4. Did you choose to enroll this program? Yes No If not, who influenced you? Parent Teacher Friend 5. How many hours do you study each day after school? 0-1hr 2-3hrs 4-5hrs more How many 6. Do you plan to attend college? Yes No Which one? 7. What colleges/universities are you interested in visiting? Please list: 8. Have you decided on any career or educational goals? Yes no If yes, list them: CAREER EDUCATIONAL Page 5
6 9. Please write an essay on the following topic: Discuss the subjects in which you had difficulty. What factors do you believe contributed to your difficulties? How have you dealt with them so they will not cause problems for you again? In what areas have you experienced the greatest improvement? What problem areas remain? Page 6
7 Page 7
8 Form #4 PARENT CONSENT FOR PARTICIPATION, AUTHORIZATION FOR MEDICAL ATTENTION, and RELEASE FOR LIABILITY Student s Name: Age: Birth Date: Address: Apt #: Phone #: City: State: Zip Code: Father s Name: Business Phone:EXT: Mother s Name: Business Phone:EXT: We (I) are (am) the parent(s) or legal guardian(s) of this child-participant, and hereby grant our (my) permission for him (her) to participate fully in said program, and hereby give our (my) permission for said child-participant to be taken to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. In consideration for being accepted by MINORITY SCIENCE AND ENGINEERING IMPROVEMENT PROGRAM, at Kennedy King College, for participation in academic, sports and enrichment activities, being 21 years of age or older, do for ourselves (myself) and for and on behalf of my child-participant, do hereby release, forever discharge and agree to hold harmless, KENNEDY KING COLLEGE and MINORITY SCIENCE AND ENGINEERING IMPROVEMENT PROGRAM, and the staff thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occurs while said child is participating in the program. We (I), on behalf of our (my) child-participant, hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and program activities involved therein. Authorization and permission is hereby given to said program staff to furnish any necessary transportation, food and lodging for this child-participant. Further, the undersigned agrees to hold harmless and indemnify said Kennedy King College and Minority Science And Engineering Improvement Program, its administrators and employees, for any liability sustained by said initiative as the result of the negligent, willful, or intentional acts of said participant, including expenses attendant thereto. TO MEDICAL PERSONNEL: We (I) authorize the adult, in whose care the minor has been entrusted to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Hospital Insurance Yes No PARTICIPANT Insurance Company Physician s Name Policy Number Phone Number Page 8
9 It is important to have certain medical information so that any emergency may be taken care of as adequately as possible. Please complete the following statements. 1. Date of last physical examination 2. Drug Allergies 3. Last tetanus immunization received 4. Is there a history of (check all that apply) hearing condition, diabetes, asthma, epilepsy, rheumatic fever, other explain: 5. Are there any physical restrictions? 6. Other conditions I understand that should a health emergency arise, I will be notified, but if I cannot be reached by telephone, such medical treatments as deemed necessary by competent medical personnel is authorized. Other than medical emergency, I authorize the University to examine and treat my child in the same way that University students are treated with notification of parents being dependent on the judgment of the physician. (Parent Signature) (Parent Signature) (Date) Name of (please print) Mother: Father: Home Phone # Mother: Father: Work Phone # Mother: Father: Pager # Mother: Father: Cell Phone # Mother: Father: Page 9
10 Form #5 Photo Release Form I hereby grant Kennedy King College, Minority Science and Engineering Improvement Program, permission to use my likeness in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of Kennedy King College Minority Science and Engineering Improvement Program, and will not be returned. I hereby irrevocably authorize Kennedy King College, Minority Science and Engineering Improvement Program, to edit, alter, copy, exhibit, publish or distribute this photo or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph. I hereby hold harmless and release and forever discharge Kennedy King College, Minority Science and Engineering Improvement from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf of my estate have or may have by reason of this authorization. If the person is under age 18, there must be consent by a parent or guardian, as follows: I hereby certify that I am the parent or guardian of, and do hereby give consent without reservation to the foregoing on behalf of this person. In addition, I give consent for the Minority Science and Engineering Improvement Program and their affiliates to take pictures of me and my family during their events. (Parent/ Guardian s Signature) (Date) (Parent/Guardian s Printed Name) Page 10
11 Page 11
Community Life Center
Community Life Center- 2018-2019 Page 2 of 6 MEGA SPORTS CAMP- Waiver & Release Forms Effective Dates: January 1, 2018 January 1, 2019 CHILD S INFORMATION Name Grade Age DOB Male/Female Nickname School:
More informationU.S. Army Aeromedical Research Laboratory Gains in the Education of Mathematics and Science Program PARTICIPANT APPLICATION
To be considered for acceptance into the 2013 GEMS program, submit the following: 1. The Participant Application 2. The Participant Essay 3. The Participant Release Form 4. Participant Safety Information
More informationSingers ONSTAGE! Registration Form
Singers ONSTAGE! Registration Form Student Information Full Name City State Zip Home Phone Date of Birth Grade (as of 9/1/15) Gender (circle one): Male Female Each registration includes two T-shirts, professional
More informationEmergency Contact other than Parent or Guardian (Required): Name: Relationship:
1 The Episcopal Diocese of North Carolina 20 HUGS Camp Special Needs CAMPER Registration Download form. Complete ALL information on computer then print and sign. This form may be saved on your computer.
More informationAugust, GA 13. June 10-15
August, GA 13 June 10-15 Jan. 16, 2013 Dear parents and students 6 th -12 th grade, Our excitement is growing for our missions opportunity this summer for all middle school and high school students. We
More informationSummer Engineering Academy
TM February 5, 2018 Aloha, Honolulu Community College is once again pleased to announce its upcoming Summer Engineering Academy. Space will be limited, so please apply as soon as possible. Only 60 students
More informationNovember 17-19, 2017
NE District High School Youth Gathering 9th-12th grade vember 17-19, 2017 LaVista Conference Center Omaha, Nebraska $200/person Registration Deadline: October 1st (Scholarships available) Late registration
More informationAdventure Club. Before and After School Care Enrollment Packet. Before and After School Care Mission:
Adventure Club Before and After School Care Enrollment Packet Before and After School Care Mission: Our before and after school care is designed to provide children with a safe, loving and exciting environment
More informationCamp Hero Registration 2017
Camp Hero Registration 2017 Camp Hero my child will be attending: June 5 9 (Joint Base Pearl Harbor Hickam location) June 26 30 (Marine Corps Base Hawaii location) I would like to register for the Extended
More informationThe Alaska Youth Academy Application
The Alaska Youth Academy Application Email to katina.charles@tananachiefs.org by June 30 th, 2016 Personal Information Please write in or circle your answer. Name: (First) (Middle) (Last ) Date of Birth
More informationThe Alaska Youth Academy Application
The Alaska Youth Academy Application Email to katina.charles@tananachiefs.org by June 26 th, 2015 Personal Information Please write in or circle your answer. Name: (First) (Middle) (Last ) Date of Birth
More informationCounselor Application 2018 July 9 th 13 th
Counselor Application 2018 July 9 th 13 th Name Address City State & Zip Home Phone Cell Phone E-mail address Male Female Birth Date (mm/dd/yy) Age (at camp) Emergency Contact Name Phone Relation to Camper
More informationSPECTACULAR All Camp Policies and Expectations
SPECTACULAR All Camp Policies and Expectations Our mission is to provide a safe, Christ centered community that encourages young women and men to discover God, their inherent worth and cultivate and express
More informationCamp TOV Medical Form
Mail: Fax: Please send these forms to us by either: Jewish United Fund/Jewish Federation of Metropolitan Chicago Attn: Camp TOV 30 South Wells Street, Room 5034 Chicago, IL 60606 Attn: Camp TOV 312-444-2086
More informationKILLEEN ALUMNAE CHAPTER of DELTA SIGMA THETA SORORITY, INC.
APPLICANT COVER SHEET Name (First, Middle & Last) Street Address City Zip Phone High School Any relatives a member of Delta Sigma Theta?. If Yes, Please list. Overall GPA Scholarship for which you are
More information2018 SUMMER DAY CAMP ENROLLMENT PACKET
2018 SUMMER DAY CAMP ENROLLMENT PACKET Enrollment : Child s Full Name: Mother s Name: AGE: Birth : Home Father s Name: Gender: (Please circle) M F Mother s Father s Mother s Home Father s Home Employer:
More informationRegistration Form Parent/Guardian Information:
Registration Paid $ Entered by: Payment : Initial Visit: Registration Form How did you hear about us? Parent #1 Parent/Guardian Information: First & Last name: Drivers License# Family Password Address
More informationSuperintendent s Regulation 4400-R Exhibit 1
Superintendent s Regulation 4400-R Exhibit 1 School Field Trip Planning Form Instructions All information on this form must be completed before presenting the form for approval to the Principal, School
More informationScholarship Guidelines and Application
Delta Sigma Theta Sorority, Inc. Ann Arbor Alumnae P.O. Box 3704 Ann Arbor, MI 48106-3704 Scholarship Guidelines and Application The Scholarship Committee of Delta Sigma Theta Sorority Inc., Ann Arbor
More informationRancho Cielo Culinary Academy ELIGIBILITY CHECKLIST
ELIGIBILITY CHECKLIST NAME: HOME PHONE: SS#: CELL PHONE: AGE: DOB: HOME ADDRESS: Step 1 Please complete the following forms included in this packet. 1. Complete the John Muir Charter School Enrollment
More informationPASADENA YMCA 2014 Winter Basketball Registration Form
PASADENA YMCA 2014 Winter Basketball Registration Form Child s Name: Date of Birth: Sex: M F Address City Zip School Height Age Grade Mother s Name Daytime Phone Father s Name Daytime Phone Signature:
More information2017 VENTURA COUNTY JUNIOR LIFEGUARD PROGRAM HELD ON SILVER STRAND BEACH IN OXNARD
2017 VENTURA COUNTY JUNIOR LIFEGUARD PROGRAM HELD ON SILVER STRAND BEACH IN OXNARD Dear Junior Lifeguard Families and prospective Junior Lifeguards: Enclosed is your 2017 PROGRAM OUTLINE. Please retain
More informationBuilding Relationships with God, Youth and our Neighbor
What: Who: Recognize that our neighbor is someone as worthy of God s love as I 2014 Theme Being Jesus Rejoicing and Sharing God s Love with the World John 3:16-18 / 2 Corinthians 13:11-13 Mission Statement
More informationTHERAPY ATTENDANCE POLICY
! THERAPY ATTENDANCE POLICY The primary focus of Dynamic Strides Therapy, Inc. s ( DST ) therapy program (the Program ) is to help the Patient named below to achieve his/her goals for therapy. We strive
More informationChico State Intelligent Systems Lab Summer Robotics Camp General Information
Chico State Intelligent Systems Lab Summer Robotics Camp 2004 General Information The Chico State Intelligent Systems Lab (ISL) has developed a week long, interactive Summer Robotics Camp to provide girls
More informationVOLUNTEER APPLICATION
VOLUNTEER APPLICATION Name: Age: Date of Birth: Social Security : Address: City: State: Zip Phone: Work: Cell: Email Address: How can we reach you? Home phone Cell phone Text Email Work phone Employer/School:
More informationWe ll meet in the Youth Room at 2:30 p.m. and we ll return by 6:30 p.m. (depending on traffic)! For students in grades 7-12.
For I was hungry and your gave me food, I was thirsty and you gave me something to drink, I was a stranger and you welcomed me. Matthew 25:35 The Dallas Life Foundation is a Christian based homeless shelter
More informationEast Baton Rouge Parish Junior Deputy
East Baton Rouge Parish Junior Deputy 2018 Application Packet Sheriff Sid J. Gautreaux, III Captain Randy M. Aguillard Program Director raguillard@ebrso.org Junior Deputy Membership Rules All members of
More informationThe Debutante Process
The Debutante Process The Arlington Foundation for Excellence in Education, formally the Xi Theta Omega Foundation, in conjunction with the Xi Theta Omega Chapter of Alpha Kappa Alpha Sorority, Inc. appreciates
More informationMILLBURY POLICE DEPARTMENT Youth Police Academy
MILLBURY POLICE DEPARTMENT Youth Police Academy The Millbury Police Department is hosting its first Youth Police Academy for the summer of 2015! Academy dates are Monday, July 27, 2015 through Friday,
More informationApplicant must have taken the ACT/SAT Test at least once and submit their scores.
HENDERSON STATE UNIVERSITY SUMMER INSTITUTE STUDENT INFORMATION SHEET Sunday, July 8-Thursday, July 12, 2018 Application deadline for ALL applications is Friday, June 4, 2018 ELIGIBILITY CRITERIA Applicant
More informationCome join the Youth Ministry for fun, fellowship and a friendly game of softball with other area Catholic High School teens.
Come join the Youth Ministry for fun, fellowship and a friendly game of softball with other area Catholic High School teens. Who do we play? Other Youth Ministries from the Dallas Diocese When do we play?
More informationSummer 2017 Multimedia Madness Youth Summer Camp Registration Form
Summer 2017 Multimedia Madness Youth Summer Camp Registration Form Mail Registration Form & Payment to MCC Business Department, 1833 West Southern Avenue, Mesa AZ 85202. Attn: Lua Maloney. PRIORITY MAIL-IN
More informationGeorgia CTI. Fall Leadership Conference (FLC)
Georgia CTI Fall Leadership Conference (FLC) Evergreen Marriott Resort November 14-15, 2013 4021 Lakeview Drive Stone Mountain, GA 30083-3099 (770) 879-9900 Hotel Reservation Deadline: October 24 Online
More information1) INFORMATION ABOUT THE PARTICIPANT AND ACTIVITY
2016-17 South Carolina 4-H Membership and Event Permission Form for Youth (Updated 08.01.16) ALL elements of this form must be completed by youth participating in clubs, field trips, events requiring group
More informationRotary District 5180/5190 RYLA REGISTRATION FORM 2018
Rotary District 5180/5190 RYLA REGISTRATION FORM 2018 ROTARY CLUB OF: ROTARY CLUB CONTACT: This form must be completed in full and signed by the student as well as a parent or legal guardian in multiple
More informationCAMP KEOLA 4-H CAMP June 19-23, 2018 CAMPER REGISTRATION NAME AGE GENDER GRADE MAILING ADDRESS CITY ZIP
COMPLETE 1 PER CAMPER CAMP KEOLA 4-H CAMP June 19-23, 2018 CAMPER REGISTRATION Camp Fee Date Received Check Number For Office Use Only WHO MAY ATTEND: Fresno County 4-H members who are 9 years old or in
More informationKANSAS PACKET INSTRUCTIONS
KANSAS PACKET ALL LOCATIONS EXCEPT HIGHLANDS AND SANTA FE TRAIL All of our programs are licensed by the Kansas Department of Health and Environment. This is a set of documents which is required by state
More informationParma High School Washington, DC Trip 2018
Parma High School Washington, DC Trip 2018 Dear Parents: Please find the attached Parents Approval Form Educational Trips Overnight / Out-of-State / Out-of-the-Country. Parents are asked to neatly print
More informationGlastonbury YMCA 29 Welles Street, Glastonbury CT Dear YMCA Family,
s Dear YMCA Family, Thank you for choosing the Glastonbury Family YMCA Preschool for your early childhood child care needs. We are excited to welcome you and your family to our program! The Y s focus is
More informationHelping others grow and excel through their interaction with horses 3498 Barclay Messerly Road Southington, Ohio 44470
Dear Prospective Volunteer: Helping others grow and excel through their interaction with horses 3498 Barclay Messerly Road Southington, Ohio 44470 Ph. (330) 889-0036 www.thecamelotcenter.org ==============================================================
More informationCourt Referral Program YDAD REGISTRATION
Court Referral Program YDAD REGISTRATION Case Number# : Name: (First) (Middle Name) (Last Name) Address: City: State: Zip: Home Phone: ( ) Cell: ( ) Work Phone: ( ) Fax #: ( ) Email Address: @. Social
More information2017 Summer Baseball 6 s & 7 s (co-ed), 8 s & 9 s (co-ed), s (boys)
Department of Parks & Recreation Recreation Division 101 Field Point Road - Greenwich, CT 06836-2540 Phone: (203) 618-7649; Email: Recreation@greenwichct.org ACTIVITY NUMBER: 10403 2017 Summer Baseball
More informationThank you for your interest in the Yorba Linda Public Library Children's Services Summer Volunteer Program!
Thank you for your interest in the Yorba Linda Public Library Children's Services Summer Volunteer Program! The Children's Services summer volunteer program provides positive and fun community service
More informationGroup Dynamix Lock-In
Group Dynamix Lock-In Group Dynamix lock-ins are certain to be tons of fun. Just imagine several hours of exciting group activities that are guaranteed to keep you going all night long. Group activities
More informationGeneral Information & Preparation
Ponderosa Retreat Parent Information Please Keep This Information Paper for your Reference All Other Forms, with $50 Payment, Turn-in by Friday, August 17 All Other Forms Must be Signed to be Valid General
More informationInformation about the VPD Cadet Program
Information about the VPD Cadet Program The VPD Cadet Program provides students in Grades 10-12 attending school within Vancouver a unique opportunity to participate in applied educational workshops, physical
More informationFAIRMAN S Skate Shop 2018 Summer Skateboarding Day Camp Programs
FAIRMAN S Skate Shop 2018 Summer Skateboarding Day Camp Programs Location: Skatepark at West Goshen Township s Robert E. Lambert Park 1045 Pottstown Pike (Rte 100 at Greenhill Road), West Chester, PA 19380
More informationJunior High Registration
St. Angela Merici Catholic Church Junior High Ministry (714) 529-1821 Ext. 147 2012-2013 Junior High Registration Welcome! The Junior High Ministry program is open to any family registered in our parish.
More informationMESA COMMUNITY COLLEGE. Information Packet 2018 YOUTH COLLEGE. Workshop I & II - Please fill out the following forms and bring to your Audition Time:
MESA COMMUNITY COLLEGE Information Packet 2018 YOUTH COLLEGE Workshop I & II - Please fill out the following forms and bring to your Audition Time: o 14 years and older Need to provide picture ID for Student
More informationGood Afternoon Parents,
Good Afternoon Parents, Thank You for looking into the Calvary Christian Mentor Program, we appreciate the opportunity to serve you and your family for the duration of summer break. Though this is a pilot
More informationAmbassador Program Application Packet
Ambassador Program Application Packet Thank you for your interest in becoming an Ambassador at Centinela Hospital Medical Center. Please complete the attached forms and then contact the Centinela Hospital
More informationSouth Park Eagle Academy Application
South Park Eagle Academy Application First Name: Last Name: Gender: Male Female Date of Birth: Commitment Level: Part Time Full Time Address Street: City: State: ZIP: Student Contact Information Email
More informationYMCA PRIMETIME PARENT/GUARDIAN:
START DATE: YMCA PRIMETIME RATE: Enrollment Form 2018-2019 SITE: Does your child have food allergies? Circle YES or NO Child s Name Gender Race Age Date of Birth Home Address, City, State, Zip Home Telephone
More informationPartners In Ministry, Inc.
Date: Partners In Ministry, Inc. Serving Richmond, Scotland, and Robeson Counties 12 Third Street Post Office Box 1621 Laurinburg, North Carolina 28352 Telephone 910-277-3355 www.pim-nc.org R.O.A.R. Work
More information2014 MASH CAMP. June 9-12 Basic (15 student limit) Grades 9-12 June Advanced (15 student limit) Juniors/Seniors ONLY
MEDICAL CAMP 2014 MASH CAMP Medical Avenues to Services in Health (M*A*S*H) programs are designed to educate High School students about the possibility of pursuing a career in the health service field
More informationJunior Baseball Spring 2017 Ages 8 & 9
ACTIVITY NUMBER: 10402 Department of Parks & Recreation Recreation Division 101 Field Point Road - Greenwich, CT 06836-2540 Phone: (203) 618-7649 Email: Recreation@greenwichct.org Junior Baseball Spring
More informationStudent Application. Student Name Nick Name. Address. City State Zip Code. Address
General Information (PLEASE PRINT CLEARLY) Residential Intensive Summer Education (RISE ) Program 2012 Student Application Cal Poly Pomona Office of Admission and Outreach, Building 98-4 th floor Attn:
More information6 th GRADE CAMP 2016 AUGUST 1 - AUGUST 5, 2016 REGISTRATION/PAYMENT INFORMATION
6 th GRADE CAMP 2016 AUGUST 1 - AUGUST 5, 2016 REGISTRATION/PAYMENT INFORMATION 6 th Grade Camp is for students entering the 6 th grade during the Fall of 2016. I will be attending with (circle one): Woodway
More information2017 Fall Field Hockey Co-ed, Grades 1-8
ACTIVITY NUMBER: 30601 Department of Parks & Recreation Recreation Division 101 Field Point Road - Greenwich, CT 06836-2540 Phone: (203) 618-7649; Email: Recreation@greenwichct.org 2017 Fall Field Hockey
More informationADOPT-A-TRAIL APPLICATION
ADOPT-A-TRAIL APPLICATION INTRODUCTION RIVERSIDE COUNTY REGIONAL PARK & OPEN-SPACE DISTRICT ADOPT-A-TRAIL PROGRAM The Adopt-A-Trail (AAT) program was developed by the Riverside County Regional Park & Open-Space
More informationReturn Completed Application To: ARISE & Ski, 635 James Street, Syracuse, NY 13203
ARISE & Ski Volunteer Application We consider applicants for all positions without regard to race, religion, creed, gender, age, disability, marital or veteran status, sexual orientation or any other legally
More information2016 Health History and Enrollment for Sam Davis Youth Camp for Youth and Adults
2016 Health History and Enrollment for Sam Davis Youth Camp for Youth and Adults Complete this form in ink answering all questions. Please print legibly The parent/guardian and camper both must sign this
More informationApplication. For The. Tyler Police Department Law Enforcement Explorer Program
Application For The Tyler Police Department Law Enforcement Explorer Program Attached are the forms that are required to be completed to be admitted into the Law Enforcement Explorer Program at the Tyler
More informationAugust 19-24, 2014 (Tuesday-Sunday)
What is EDGE Adventure Camp? A five day Catholic camp with sports & activities including canoeing, kayaking, giant rope swing, water sports and more! Live music, catechesis, Mass, praise & worship and
More informationTown of Madison Beach and Recreation Department After/Before School Program 8 Campus Drive Madison, CT Phone: (203) /Fax: (203)
Per Connecticut General Statute 19a-77 we are required to disclose that our programs are not licensed by the State Office of Early Childhood. Dear Parent: To enroll your child(ren) in the, please complete
More informationDear Parent/Guardian,
Dear Parent/Guardian, Thank you for your interest in Nathan Adelson Hospice s Camp Erin. Camp will be held June 1 st 3rd, 2018. We are very excited and looking forward to another great camp experience!
More informationJelly Belly Factory. Back By Popular Demand: We will tour the
Back By Popular Demand: We will tour the Jelly Belly Factory in Fairfield on our way to the campsite. For a full itinerary see the reverse side of this flyer. Who: ALL 8th-12th graders What: White water
More information2018 MARSHALL COUNTY LAW ENFORCEMENT YOUTH CAMP APPLICATION
2018 MARSHALL COUNTY LAW ENFORCEMENT YOUTH CAMP APPLICATION Law Enforcement agencies from across Marshall County will sponsor and provide a Law Enforcement Youth Camp for students this year on the dates
More informationUniversity of North Texas UNTWISE Attention: Live and Learn Summer Program 1155 Union Circle # Denton, Texas
Greetings from UNTWISE! Workplace Inclusion and Sustainable Employment Department of Rehabilitation and Health Services We are excited you are considering attending the Live and Learn Summer Program! Included
More informationVirginia Association of the Technology Student Association
Virginia Association of the Technology Student Association TO: FROM: SUBJECT: PO Box 9045, VSU, Petersburg, VA 23806 Phone: (804) 524-5549 Fax: (804) 524-5757 email: StateAdvisor@VirginiaTSA.org Website:
More informationCollege of Health Drug/Alcohol Policy
College of Health Drug/Alcohol Policy All dental and nursing students are expected to be free from any influence of drugs and/or alcohol while in class and during all clinical/lab experiences. All dental
More informationU.S. Martial Arts Academy SUMMER CAMP 2015
U.S. Martial Arts Academy SUMMER CAMP 2015 3430 Oak Road Vineland, NJ 08361 Hours of operation 7:30am-5:30pm (Monday-Friday) Dates of Operation: Monday June 22nd thru Friday August 28th CLOSED WEEK OF
More informationUniversity Health Services and Safety. Occupational Health & Safety Guideline
Advisory 21.0 Persons under 18 years of age are not allowed in laboratories where hazardous substances (chemicals, biologicals, etc.) are present or physical hazards (very hot or cold temperatures, laser
More informationStudent T-shirt size is: Small Medium Large XLarge 2XLarge 3XLarge (Circle one)
Participant Permission Form/ Release Waiver Form My child,, has my permission to attend. I understand this celebration is offered to all graduates who have signed and maintained both the Project Grad Participant
More informationAttention High School Students:
Attention High School Students: Annually, Hopewell Federal Credit Union (HFCU) offers a scholarship to a local student pursuing secondary education. The winner of the HFCU scholarship will be awarded $1000
More informationEnrollment Application
Office Use Only Campus Level: Beginner/ Advanced/ Senior Paid: Shirt Size: Enrollment Application The Anaheim Police Cops 4 Kids Jr. Cadet program is a semi-military based program emphasizing respect,
More information2017 Summer Camp Registration
1515 N. Galloway Avenue Mesquite, Texas 75150 972.216.6260 www.cityofmesquite.com 2017 Summer Camp Registration Please select which camp your child(ren) will be attending BLAST Camp Sports Camp Teen Camp
More informationMEMBER APPLICATION FORM
YMCA of Orange County- New Horizons 13821 Newport Ave, Suite 150, Tustin, CA 92780 Phone: (714) 508-7635, Fax (714) 508-7607 newhorizons@ymcaoc.org www.ymcaoc.org/nh MEMBER APPLICATION FORM PROGRAM DESCRIPTION
More informationYMCA Before and After School Care School Year YMCA OF PIERCE AND KITSAP COUNTIES
PARENT INFORMATION PAGE: Please save for All your fields reference must be completed for PENINSULA registration packet SCHOOL to be considered DISTRICT complete. YMCA Before and After School Care 2017-2018
More informationStudent Admission Application Form
Student Admission Application Form Application for Std/Form Year Term Student Details: Surname D.O.B. Nationality No. Siblings at TLCS Birth Certificate/ Health Records Copy of Current Residence Permit
More informationCALIFORNIA DEPARTMENT OF FORESTRY AND FIRE PROTECTION CDF (Page 1)
CALIFORNIA DEPARTMENT OF FORESTRY AND FIRE PROTECTION CDF 670 - (Page 1) VOLUNTEER IN PREVENTION APPLICATION AND SERVICE AGREEMENT CDF-670 NAME MALE HOME PHONE FEMALE WORK PHONE CITY/TOWN ZIP EMAIL SOCIAL
More informationSanta Margarita Catholic High School Girl s Soccer
Welcome Eagles! This booklet contains all of the information and approval forms that must be completed, signed, and returned by the parents of all players before the player will receive their uniform and
More informationGlastonbury Family YMCA. CAMP GLAWACKUS, CAMP LIGER and SPECIALTY CAMPS REGISTRATION PACKET
2018 Glastonbury Family YMCA CAMP GLAWACKUS, CAMP LIGER and SPECIALTY CAMPS REGISTRATION PACKET CAMP LOCATION 30 High Street South Glastonbury, CT 06073 860-541-1812 STEP STEP one REGISTRATION Done online,
More informationRETURNING STUDENT INFORMATION UPDATE
ST. FRANCIS CATHOLIC SCHOOL Student Information Date: RETURNING STUDENT INFORMATION UPDATE Student Name Last First Middle I Nickname Birth Date Gender Grade Entering Birth Country Birth City Birth State
More informationRETURN COMPLETED FORMS AND FEE TO YOUR CHILD S SCIENCE TEACHER by Wednesday, March 4, Camp Parent Meeting, March 3rd, 6:30 pm, Cafeteria
RETURN COMPLETED FORMS AND FEE TO YOUR CHILD S SCIENCE TEACHER by Wednesday, March 4, 2015 Camp Parent Meeting, March 3rd, 6:30 pm, Cafeteria February, 2015 Dear Parents: After several years of 7 th graders
More information2007 SUMMER VOLUNTEEN PROGRAM APPLICATION PACKET
2007 SUMMER VOLUNTEEN PROGRAM APPLICATION PACKET The complete application is due back to the Human Resources department at Baptist South no later than the end of day on Monday, April 23 rd. Baptist Medical
More informationRhode Island College Club Sports Emergency Information Form
Rhode Island College Club Sports Emergency Information Form Contact Information Name: Email: Phone Number: Club Sport: Student ID #: Year in School: Local Address: (Street) (City) (State) (Zip) Person
More informationROCK PAPERWORK CHECKLIST
ROCK PAPERWORK CHECKLIST Thank you for registering for the ROCK Before/After School Program, a ministry of Zionsville United Methodist Church. Please make sure you have each of the following documents
More information2017 VolunTEEN Scheduling Form. SHIRT SIZE: S M L XL XXL **sizes run big
2017 VolunTEEN Scheduling Form NAME: PHONE #: SHIRT SIZE: S M L XL XXL **sizes run big Indicate below your preference of shift by numbering the blocks by 1 st, 2 nd and 3 rd choice. If you have two first
More informationParent/Guardian Names: Cell Phone: School: Parent/Guardian Signature: Date:
SPIRIT OF AMERICA BOATING SAFETY PROGRAM Offered by Sailing Center Chesapeake & St. Mary s College of Maryland Open to students who have completed 6 th, 7 th, or 8 th grades in 2017. Summer 2017 Student
More informationAMERICAN INDEPENDENCE YOUTH LEADERSHIP CONFERENCE PLEASE PRINT NEATLY. Street Address. City. circle one Comments. Zip Code
AMERICAN INDEPENDENCE YOUTH LEADERSHIP CONFERENCE ENTER CONFERENCE DATES: PLEASE PRINT NEATLY First Name and M.I. Last Name Home Phone Street Personal Cell Phone City State Zip Code Parent(s) last name
More informationTo begin the application process, please complete the enclosed application and bring it with you to one of our weekly meetings.
Dear Explorer Applicant, We are pleased that you have shown interest in the Miramar Police Department Explorer Program. The Explorer program is the best program that young men and women can become involved
More informationKairos Retreat for Teens [SFK13] September 22, 23, 24 & 25 th, 2016
For Juniors & Seniors in High School What is Kairos? Kairos, which means Lord s Time, is a Christian experience of prayer and reflection, run by a team of adults and trained peer leaders. St. Francis de
More informationTEXAS. Technology Students Association FORMS
TEXAS Technology Students Association FORMS 2017-2018 1: Texas TSA Protest Form. Please note that protest for NQE Entries MUST use the National TSA Protest Form Form found below and in the National TSA
More informationRegistration Form Needs completed, signed with Notary, and a copy of insurance card included (if applicable).
CAMPER PACKET INCLUDES: Registration Form Needs completed, signed with Notary, and a copy of insurance card included (if applicable). Code of Conduct signed by students and parents with dates. Suggested
More informationAfter School Program ABBOT DOWNING SCHOOL BEAVER MEADOW SCHOOL
@ Y 21C Y@21C is a partnership between the 21st Century Community Learning Centers and the Concord Family YMCA. PLEASE NOTE: registration must be confirmed by the YMCA before your child can attend program.
More informationNORTH CAROLINA 4-H VOLUNTEER APPLICATION
NORTH CAROLINA 4-H VOLUNTEER APPLICATION PERSONAL INFORMATION First Name: Middle Name: Last Name: Suffix: Preferred Name: Mailing Address: Mailing Address 2: City: State: Zip: Gender: Male Years in 4-H:
More informationCAMPER REGISTRATION FORM INSTRUCTIONS
T O T H E D A Y C A M P CAMPER REGISTRATION FORM INSTRUCTIONS Thank you for choosing the Flock to the Kroc Day Camp for this summer. Our payment process will be completed online this year. Please follow
More informationTEEN VOLUNTEER APPLICATION. Last Name, First Name, Middle Initial. Home Address ~ Number, Street, Apt. # City State Zip Code
Teen 14 ½ to 17 yrs. old Arrowhead Regional Medical Center 400 N. Pepper Avenue Colton, California 92324 (909) 580-6340 TEEN VOLUNTEER APPLICATION When completing this application, please Print Info. in
More information