Academy of Mount St. Ursula

Academics | Arts | Service

Academy of Mount St. Ursula

Summer Preparatory Program

Directions: Please read and complete all sections, both front and back. Note that the completed application and full, non-refundable payment by check or money order is due by May 1st. Please mail both the application and the payment to: Academy of Mount St. Ursula, Admissions Office, 330 Bedford Park Boulevard, Bronx, NY10458.

I. Program Information:

Please place a check mark next to the summer program in which you would like to enroll:

_____ STAR PROGRAM

-Meets from 9 am to 12 pm, Monday through Friday, from Tuesday, June 28th through Friday, July 22nd (no classes on Friday, July 1St and Monday, July 4th) Cost: $300

_____ MATH PREP AND STUDY SKILLS

-Meets from 9 am to 12 pm, Monday through Friday, from Tuesday, June 28th through Friday, July 22nd (no classes on Friday, July 1St and Monday, July 4th) Cost: $225

_____ ELA PREP AND STUDY SKILLS

-Meets from 9 am to 12 pm, Monday through Friday, from Tuesday, June 28th through Friday, July 22nd (no classes on Friday, July 1St and Monday, July 4th) Cost: $225

_____ BOTH MATH AND ELA PREP

-Meets from 9 am to 12 pm, Monday through Friday, from Tuesday, June 28th through Friday, July 22nd (no classes on Friday, July 1St and Monday, July 4th) Cost: $225

______ALL THREE COURSES (MATH, ELA AND STUDY SKILLS)

-Meets from 9 am to 12 pm, Monday through Friday, from Tuesday, June 28th through Friday, July 22nd (no classes on Friday, July 1St and Monday, July 4th) Cost: $300

II. Student Information:

Name:______Date of Birth______

(Last) (First)

Address:______City:______Zip:______

Home Phone:______E-mail: ______

Elementary/Middle School:______

III. Parent/Guardian Information:

Student lives with: ______

Parent email: ______

Parents’ Names:

Father______Cell#______

Occupation:______Business# (incl. ext)______

Mother______Cell#______

Occupation______Business#(incl. ext)______

IV. Emergency Contact Information:

1) Name:______Relationship:______

Phone Number:______

2) Name:______Relationship:______

Phone Number:______

V. Parent/Guardian Consent:

I hereby ask permission for my daughter /child in my care to participate in the above-named summer program at the Academy of Mount St. Ursula. I understand that payment is non-refundable.

______

(Print Name)(Signature) (Date)

VI. Medical Conditions/Allergies:

In the space provided, please list any documented medical or health issues your daughter has, including allergies. Please also note any special concerns you may have regarding your daughter’s general health and well-being

VII. Medical Emergency Aid:

Please sign your consent to the following statement regarding medical emergency aid:

In the event of an emergency, in which the school cannot contact me or authorized family members, I ask the Academy of Mount St. Ursula to obtain necessary emergency medical treatment for my daughter. It is understood that the school will continue efforts to reach me as soon as possible.

______

(Print Name)(Signature) (Date)

VIII. Public Relations Consent:

Please check one of the following statements regarding public relations consent, then sign and date below:

_____ I give permission _____ I do not give permission

for my daughter/child in my care to be photographed/videotaped while enrolled in the Academy of Mount St. Ursula’s Summer Preparatory for the possible use of publicity for the school.

______

(Print Name)(Signature) (Date)

330 Bedford Park Boulevard | Bronx, NY 10458 |

P: 718-364-5353 | F: 718-364-2354