WELCOME TO SUMMER LEADERSHIP ACADEMY
at Gilbert Stuart Middle School
What is SLA?
Looking for a fun and exciting way to kick off next year at school? Want to get an inside look and feel of your middle school before September? Want to meet other students entering middle school all while having a great time? Join this year’s Summer Leadership Academy.
Providence Public School District (PPSD) and City Year are teaming up to bring this unique opportunity to students entering Gilbert Stuart Middle School. For one week in August, you can spend time at your school doing a variety of activities ranging from sports, to arts and music, to hands-on science and so much more!
• Students are required to attend ALL days that the Summer Leadership Academy is in session from: August 15, 2016 – August 19, 2016, from 8:00 AM – 3:00 PM. Students who have more than two unexcused absences or cannot follow the code of conduct will be removed from programs.
• The Summer Leadership Academy is a FREE program and includes breakfast and lunch. Transportation is provided to your school and neighborhood bus stop for pickup and drop-off.
• Youth will spend their day with a team of adult educators who will serve as guides during their experience.
• Student will have the opportunity to sign up for a different enrichment program, such as arts, sports or skill based activities.
Please note that students are enrolled on a “first-come, first-served” basis, so the sooner your child returns this application, the more likely they are to have a spot. We can’t guarantee that students will be enrolled in the program; parents will receive written confirmation and a phone call to notify if their child has been accepted for program.
All student participants must have a completed and signed application form from a parent/guardian to be considered. Attached you will find an application and photo release and liability waiver for the week. We look forward to seeing you there!
To learn more about City Year please visit www.cityyear.org
For more information on the Summer Leadership Academy, please contact:
City Year Providence
401.454.3747
We speak Spanish
SUMMER LEADERSHIP ACADEMY APPLICATION
• Return completed forms to your school's main office, or City Year office at 275Westminster Street, Providence, RI.
• ALL sections must be complete before you submit this form. This includes the signature of a parent or legal guardian.
• Programs are free, and students will be enrolled on a "first-come, first-served" basis. We cannot guarantee that students will be enrolled in programs that are selected. Families will receive written confirmation and a phone call letting them know if their student has been accepted for particular programs.
• Students are required to attend Monday through Friday, August 15, 2016 – August 19, 2016, from 9:00 AM – 3:00 PM
• Students who have more than two unexcused absences or cannot follow the City Year code of conduct can be removed from programs.
• School Bus transportation to home neighborhoods is provided for all youth participating in the Summer Leadership Academy if parents give approval. Parents are always welcome to pick up students at the end of the program day.
Student Information Please complete the information in its entirety.
Full Name:
Birthdate: Gender:
Elementary School
Student ID: Attended:
Emergency Contact Information
* Parent / Guardian 1 / Emergency Contact / * Parent / Guardian 2 / Emergency Contactname: / name:
relationship: / relationship:
home phone: / home phone:
work phone: / work phone:
other phone: / other phone:
email: / email:
address: / address:
city: / city:
state: / zip: / state: / zip:
Medical Information
This information will not affect your child's enrollment. City Year will work with you to possibly gain additional support and make necessary accommodations.
Medication: Yes: / No: / If so, please explain:______Allergies: Yes: / No: / If so, please explain:______
Below, please describe any disability or chronic or recurring illness we should be aware of:
Transportation
At the end of the day, school bus transportation to home neighborhoods is provided for all young leaders participating. Providence School District’s transportation office will provide corner stops for your son/daughter. If a young leader does not have permission to walk or take a bus home at the end of the day, he/she must be picked up by a person on the pick-up list below at 2:45 on all program days.
My child may be picked up by:
name: / relationship: / phone:name: / relationship: / phone:
name: / relationship: / phone:
Please add as many names to this pick- up list as you like on an additional sheet of paper. Only those listed above or on your additional sheet will be allowed to pick up students.
My child may NOT be picked up by:
name: / relationship: / phone:name: / relationship: / phone:
name: / relationship: / phone:
Please check yes or no for EACH statement. It is important that we know your preferences for EVERY option listed below:
yes no
yes no
yes no
yes no
I will pick my child up at the school at the end of the day.
I grant my child permission to walk home alone from his/her school at the end of the day.
I grant my child permission to take the school bus in the morning and back home in the afternoon.
In the event that myself and the persons authorized for pick up are not able to arrive on time, City Year staff will allow my child to take the school bus to the appropriate corner stop.
Permission – Media Release
For good and valuable consideration, the receipt and sufficiency of which I hereby acknowledge, I agree as follows:
1. I hereby irrevocably grant City Year, Inc. (“City Year”), its partners and sponsors, including - but not limited to - national leadership sponsors, team sponsors and ‘give a year’ college partners, and others working for City Year or on its behalf, and their respective licensees, successors and assigns (hereinafter collectively referred to as the “Licensed Parties”) a right to use, distribute, publish, exhibit, digitize, broadcast, display, reproduce, and otherwise use my photograph, likeness or any material based upon or derived therefrom, or to refrain from doing so, in any manner or media whatsoever, anywhere in the world, in perpetuity, for the purpose of advertising, marketing or trade.
2. I agree that no advertisement or other material need be submitted to me for any approval and the Licensed Parties shall be without liability to me for any distortion or illusionary effect resulting from the exhibition, publication, broadcast or other use of my photograph and likeness.
3. I warrant and represent that I am 18 years of age or older, and that this license does not in any way conflict with any existing commitment on my part. If I am not yet 18 years of age, I warrant and represent that my father, mother or guardian consents and personally joins in the warranties and representations in this release as indicated by his/her signature below.
4. Nothing herein will constitute any obligation on the Licensed Parties to make any use of the rights set forth herein. I agree that this license supersedes all prior negotiations and understandings between myself and the Licensed Parties relating to the rights granted herein.
FULL NAME PRINTED /SIGNATURE /
DATE
ADDRESS /
CITY STATE ZIP
I am the (father-mother-guardian) of above-mentioned minor. I consent to the foregoing on behalf of said minor and personally join in the warranties and representations set forth above. I also agree to indemnify, defend and hold the Licensed Parties harmless with respect to any claims that said minor may make as a result of the exercise by the Licensed Parties of their rights hereunder.
FULL NAME PRINTED /SIGNATURE /
DATE
ADDRESS /
CITY STATE ZIP
For more information on the Summer Leadership Academy, please contact:
City Year
P: 401-454-3747
Waiver and Release Form for Summer Leadership Academy Liability Release and Parental Consent Form
In consideration of the acceptance of my application for the above program, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to me as a result of participation in said event. This release is intended to discharge in advance City Year, its staff and corp members, Summer Leadership Academy volunteers and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assignees.
Parental Consent (Complete if applicant is under 18)
I give consent for my child ______to participate in the above activities, and I execute the above liability release on their behalf.
Consent for Treatment
I hereby give my consent to have the above applicant treated by the on- site certified nurse. It is understood that Summer Leadership Academy will provide no medical insurance for such treatment, and that the cost thereof will be at my expense. I have read and understood the foregoing registration liability release and parental consent form, and agree to all of its terms and conditions.
Parent/Guardian Signature ______
Print Name______
Date ______
SLA Participant Signature______
Print Name ______
Date______