Applications must be submitted byFriday June 5, 2015

CREC Polaris Center Summer Credit Recovery,

474 School St, East Hartford, CT 06108; Fax: 860-289-8380

Email: .

Student Name: ______Date of Birth: ______

Parent/Guardian Name:______

Address: ______

Cell Phone: (______) ______Home Phone:(______) ______

Work Phone: (______)______Email: ______

Student Address:(if different) ______

Primary Language: Student ______Parent/Guardian______

School District ______School last attended: ______

Grade going into fall 2015: ______School fall 2015: ______

Is the student identified as Special Ed? YES NO If yes, primary disability: ______

Please attach most recent Individualized Education Plan.

COURSES OFFERED:

English:9101112

Math:General/Consumer MathAlgebra 1 Geometry

Social Studies: US History CivicsWorld History

Science:Physical ScienceChemistryEarth Science

(NO LAB

COMPONENTS)Biology/Life Science

SESSIONS, maxof 1 credit per session:Course Requested(from list above)

1 – Monday 6/29/15 – Friday 7/17/15______

2 – Monday 7/20/15 – Friday 8/7/15______

Breakfast and lunch are provided daily.

CREC Polaris Center’s Credit Recovery courses meet Connecticut subject area standards. Curriculum is derived from student’s area of identified missed instructional units and/or full course overview. Students may only participate if they have failed a course, not to complete upcoming required graduation requirements.

Courses may only be taken for full credit, we’re not able to provide instruction for partial credit courses.

Classes are taught by special education teachers who are able to instruct regular education and/or special education students.

It is strongly recommended that you contact your student’s guidance counselor to notify them of the student’s pending enrollment, to ensure that the school/school district will accept courses taken through the CREC Polaris Center’s Summer Credit Recovery program, to be applied to the above student’s transcript and graduation requirements.

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Program Selection and Payments:

The cost for one full credit is $450.00; maximum of two credits for full summer.

Total Number of Credits: ______X $450.00 = Total Due $______

Please indicate which session(s) you would prefer to attend.

_____ Both Sessions: June29 – August 7up to two credits possible

_____ Session One: June 29 – July 17, 8:30am-1:00pm, one credit possible

_____ Session Two: July 20 – August 7, 8:30am-12:30pm, one credit possible

Payments may be made by:

  • Cash
  • Credit Card (MC or Visa accepted)
  • Bank check/ Money order, payable to CREC POLARIS CENTER
  • or Memorandum of Agreement,for Agency use (below)

Memorandum Agreement for Payment

______agrees to pay the tuition cost of $______.00 for

(Choice/LEA/Agency)

______to attend this program and earn a total of _____ credit(s).

Signed ______

Printed Name/Title of Primary ContactSigned______

Printed Name/Title of Supervisor or Administrator

A copy of immunization record & last physical exam will be required prior to the first day of attendance.

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2015 Summer Programs Standard Permissions

Child’s Last Name First Name / Date of birth

Child lives with: □ Mother □ Father □ Both Parents

□ Other/Guardian(please specify): ______

Referring Party Name: ______Phone: ______

Agency: _____ DCF _____Probation _____Parole _____Other: ______

Parent/Guardian Name: ______

Address: ______

Home Phone: ______ Cell Phone: ______

Work Phone: ______

Email (optional) ______

If your child needs to go home early, who do you prefer we notify first?

□ Mother □ Father □ Other/Guardian (please specify): ______

At what phone number? ______

For other non-urgent matters, how do you prefer we contact you?

□ Cell □ Work □ Home □ Send note home

□ Other (please specify): ______

In case of an emergency, illness or other reason and parent/guardian cannot be reached, please list the names of up to three (3) persons to call whom you authorize to transport and assume responsibility of your child.

Name / Relationship / Phone Number with area code
1
2

Student Health History

Please circle Y if “yes” or N if “no.” Explain all “yes” answers in box provided on next page.

Any health concerns Y N / Hospitalization or E. Room visit Y N / Concussion Y N
Allergies to food or bee stings Y N / Broken bones or dislocations Y N / Fainting or blacking out Y N
Allergies to medication Y N / Any muscle or joint injuries Y N / Chest pain Y N
Any other allergies Y N / Any neck or back injuries Y N / Heart problems Y N
Any daily medications Y N / Problems running Y N / High blood pressure Y N
Any problems with vision Y N / “Mono” (past 1 year) Y N / Bleeding more than expected Y N
Uses contacts or glasses Y N / Has only 1 kidney or testicle Y N / Problems breathing/coughing Y N
Any problems hearing Y N / Excessive weight gain/loss Y N / Any smoking Y N
Any problems with speech Y N / Dental braces, caps, or bridges Y N / Asthma treatment (past 3 yrs) Y N
Diabetes Y N / ADHD/ADD Y N / Seizure treatment (past 2 yrs) Y N

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Child’s Last Name First Name / Date of birth
Any YES answers from Student Health History above, explain:
Hospital Preference:
Standard Permissions:
The school nurse has permission to share health information with staff members for health and safety purposes? / YES / NO
Will your child require prescription medication during program hours? / YES / NO
Name(s) of medication and time required:
If Yes,we’ll need a supply of medication(s) AND a Medical Authorization Form from a doctor or nurse practitioner. Students may carry some medications, per program RN and CREC Health Services guidelines. Contact the nurse’s office at (860) 289-8131 x3430 with any questions.
Please circle whether or not you give permission for your child to have:
Tylenol (Acetaminophen) for fever, headache, menstrual cramps, bone or muscle pain, or dental pain, according to our standing physician’s orders? / YES / NO
Ibuprofin for menstrual cramps or muscle pain? / YES / NO
“Off” Skintastic Bug Spray, if requested/as necessary? / YES / NO

______/_____/_____

Print Parent/Guardian Name Date

______

Signature Parent/Guardian

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474 School Street, East Hartford, CT 06108 860-289-8131  