Summer Academy

2017Application forElementary RTI, ENLPrograms

Where: Beverly J Martin Elementary

When: July 10,2017 – August 4, 2017

Monday-Friday 7:45am -11:15am

Families must submit applications to their child’s school by May22nd, 2017. Applications received by the school principal will be reviewed and recommendations made to the Summer Academy program.Applications must be forwarded by the school to TST BOCES by May 24th. If the student meets the criteria for Summer Academy, T-S-T BOCES will notify families of their acceptance by June 2nd.

Student Name: ______

(First) (M.I.) (Last) (DOB: MM/DD/YYYY)

Home Address: ______

(Street) (City) (Zip code)

Parent/Guardian Name(s): ______

(First) (Last) (Relationship to Student)

Parent/Guardian Name(s): ______

(First) (Last) (Relationship to Student)

Parent/Guardian Phone:______

(Home) (Cell) (Work)

Emergency Contact: ______

(Name)(Phone #)(Relationship to Student)

Emergency Contact: ______

(Name)(Phone #)(Relationship to Student)

I request Summer Academy services for my child named above. My child and I have read and agree to the Code of Conduct, see bottom of page 2.

Parent/Guardian signature:______Date:______

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MEDICAL INFORMATION: In case of emergency, I understand that my child will be transported to the nearest medical facility and that I will be notified as soon as possible. I give my consent and authorization for any first aid medical treatment to be made including any diagnostic procedure, medical, dental, surgical care and hospitalization determined advisable by any physician, dentist or hospital personnel providing health to my child.

Please list any allergies to conditions your child has (i.e., medications, sun, food, plans, bee stings, motion sickness, etc.) ______

Please list any major illness or injury, including chronic conditions (asthma, diabetes, and seizures):

______

Please list any medications your child takes: ______

Is Transportation needed? (Circle one)YesNo

PICKUP AND DROPOFF INFORMATION: If your child needs to be picked up or dropped off at a different address (other than the address listed above), please list this information below.

PICKUP Address:______

DROPOFF Address: ______

____Cass Park_____ Home only

____ Stewart Park Camp_____ Day care

____ Enfield School—Summer Program_____ GIAC

____ Cayuga Heights School- Summer Program_____ OTHER: ______

List any other adults who have permission to pick up the student in case student is sick or in need of an appointment (please include the adult’s phone number):

______

______

Order of Protection: If the student has an order of protection, please provide a copy of the order with this application.

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Photo Consent:

Photographs may be taken during the summer program by local media. Please check belowifyoudo not want your child’s photograph or name used for any purposes.

____ I DO NOT WANT MY CHILD’S PHOTO AND/OR NAME RELEASED FOR ANY REASON

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Please return this application to your school office.

Thank you,

Maxine Parker, Supervisor of External Programs at TST BOCES

Diahann Hesler, Director of External Programs, Career & Technical Education, and Adult Education at TST BOCES

TST BOCES Summer AcademyCode of Conduct

Elementary Students at Summer Academy will help learners learn and teachers teach by:

  • Following all school rules
  • Respecting themselves, others and property
  • Working cooperatively
  • Taking responsibility for their own actions
  • Acting in a safe and polite manner

______

To be completed by sending district:

School District: ______

Student ID#: ______Student Gender: ______

Program: RTI/ENL (circle one)

Does the student have a BIP? Yes / No (circle one)

Does the student have an IEP? Yes/No (circle one)

Does the student have a 504 plan? Yes/No (circle one)

Fountas & Pinnell Benchmark Year End Instructional Level ______

2016-17 Teacher’s Name: ______Student Grade 2016-17: ______

School:______

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