NORWALK PUBLIC SCHOOLS

STUDENT EMERGENCY INFORMATION CARD

SUMMER PROGRAM 2016

STUDENT NAME ______

SCHOOL ______ENTERING GRADE_____ BIRTH DATE ____/______/____

HOME ADDRESS ______HOME TELEPHONE ______

MOTHER’S /GUARDIAN’S NAME ______

HOME ADDRESS ______HOME PHONE ______

(if different than Student’s)

CELL PHONE ______WORK PHONE ______

EMAIL ______

FATHER’S /GUARDIAN’S NAME ______

HOME ADDRESS ______HOME PHONE ______

(if different than Student’s)

CELL PHONE ______WORK PHONE ______

EMAIL ______

FAMILY STATUS

If a parent who has exclusive custody of his/her child wishes the school to not release the child to the non-custodial parent, the custodial parent must provide the school with a copy of the divorce decree or separation agreement which restricts the access rights of the non-custodial parent.

1) _____ Applies and will furnish relevant documents to the school. 2) _____ Does not apply.

EMERGENCY CONTACT INFORMATION

In the event of illness or an emergency, it may be necessary to contact you or a friend. Please indicate below in order of preference, those whom we should call if unable to reach either parent.

NAME ______RELATIONSHIP ______ADDRESS ______

TELEPHONE ______CELL PHONE ______

FAMILY PHYSICIAN ______TELEPHONE ______

PARENT/GUARDIAN SIGNATURE ______DATE ______

MEDIA RELEASE FORM

STUDENT NAME ______

PF Camp Summer Program MEDIA ACCESS POLICY PERMISSION FORM

The Norwalk Public Schools require written consent of parent(s) or guardian(s) before students are interviewed, filmed or photographed by media representatives. During the coming summer, your child may be involved in an activity with the media at our summer program site therefore, we ask you to kindly sign the release form below.

I DO/ I DO NOT

give permission for my child to be interviewed, photographed, and/or filmed by media representatives during the current summer.

I DO / I DO NOT

give permission for my child to have photo(s) and/or Camp project work, published on the NPS school Web site using first name only.

PARENT/GUARDIAN SIGNATURE ______DATE ______

Elementary and Middle School

PERSONAL FULFILMENT CAMP APPLICATION

Summer 2016

Camper:

______

Last NameFirst Name Mailing Address Town Zip Code

Parent/Guardian:

______

Last Name First Name Phone Number:

School Attended: ______Grade Completed:______

Camp Info:

  • Elementary (K- 5th Grade)Location: Nathan Hale Middle School

Time: 9:10am-3:10pm

  • Middle (5th-8th Grade)Location: Norwalk High SchoolTime: 9am-3pm

(Completed 5th graders with younger siblings have the option to stay in the elementary camp. All others enroll in the middle school camp)

Camp Weeks Desired:

  • Week 1: June 27-July 1
  • Week 2: July 5-8 no camp on July 4th due to the holiday)
  • Week 3: July 11-15
  • Week 4: July 18-22
  • Week 5: July 25-29

Cost: Make checks payable to: Norwalk Summer Programs. Checks returned for insufficient funds will be charged $25.00.

1 Week / 2 Weeks / 3 Weeks / 4 Weeks / 5 Weeks
$195.00 / $360.00 / $510.00 / $630.00 / $700.00

* Camp Fee INCLUDES one camp T-shirt per Camper for ELEMENTARY SCHOOL ONLY

***Additional shirts can be purchased for $12.00 each for elementary campers only.

***Circle the size – CHILD:____S ____ M____ L____ XL Additional Quantity

ADULT: ____ S ____M____ L ____XLand size: ______

ABSOLUTELY NO REFUNDS AFTER THE START OF CAMP!

2016 DISCOUNTS! $15 off each child registered by April 1! (Must be paid-in-full)

Other Important Information/Accommodations Camp Staff should be aware of:

  • IEP ______
  • 504______
  • Allergies ______
  • Other: ______