For Program Staff Use Only Date received form: Transportation:  Parent pick up / drop off  Bus transportation

Registration confirmed with parent Name/ Date:

Intervention  Yes  No Weeks Attending:

To start the registration process for the Norwich Public Schools Summer Learning Program please complete the following form. Return completed form to: 6th Grade Academy at TMMS (15 Teachers Dr. Norwich, CT 06360) by May 30th, 2017.

Student Information Last Name:

First Name:

School/ Current Grade:

Birth Date: /

Sex:

/

M

F

Home Address:

Contact Information Parent/Guardian #1

Email Address:

Home Phone:

Employer:

Cell Phone:

Employer Address:

Parent/Guardian #2

Email Address:

Home Phone:

Employer:

Cell Phone:

Employer Address:

Emergency Contact #1 Name:

Relationship:

Phone:

Authorized to pick up? Y N

Emergency Contact #2 Name:

Relationship:

Phone:

Authorized to pick up? Y N

NO CONTACT INFORMATION: Please indicate if legal restrictions are in effect. List persons not allowed to see student on site and/or persons not allowed to pick- up students per legal restrictions. Legal documentation must be provided for parental restrictions to the program.

First &Last Name(s):

Transportation Bus transportation will be provided the weeks of June 19th-June 30th and July 17th-August 4th for the program hours of 8:30 am- 3:30pm. Bus transportation will not be provided for students who attend before or after care programs and for the weeks of July 10th- 14th and August 7th- 11th.

My child will:



take bus transportation



be driven to the program by a parent or guardian

Medical Information If registering multiple children, please include child’s name.

Allergies: Medical conditions: Medications to be administered during program hours: If my child needs to be taken to an emergency facility, he/she will be taken to Backus Hospital. I give my consent for program administration to take appropriate action for the safety and welfare of my child.

 Yes

 No

Additional Registration Information Photo/Video Release: I give permission for the program to use my child’s image in online and print materials.

 Yes

 No

Program Policies and Procedures: I have read the Norwich Public Schools Summer Learning Program policies and procedures including; attendance and behavior policy.

 Yes

 No

Program Enrollment Day Summer Program Weeks Attending: (8:30am-3:30pm)

Check Off

Before Care (6:30am– 8:30am)

After Care

(3:30pm-5:30pm)

Program Weeks: June 19th- August 11th

$875

$140

$140

Week 1: June 19th- 23rd

$125

$20

$20

Week 2: June 26th- 30th

$125

$20

$20

Week 3: July 10th- 14th

$125

$20

$20

Week 4: July 17th -21st

$125

$20

$20

Week 5: July 24th – 28th

$125

$20

$20

Week 6: July 31st- August 4th

$125

$20

$20

Week 7: August 7th- 11th

$125

$20

$20

Please note: There is no program the week of July 3rd Parent/Guardian Name:

Date:

Parent/Guardian Signature:

Date:

Financial Aid Please read the terms to receive financial aid for the NPS Summer Learning Program. A signature agreeing to these terms is required for this application to be considered complete. I understand:  Financial aid is not available for before care and after care programs.  My financial aid application will not be accepted unless the below questions are accurately completed and proof of income is submitted.  Accepted forms of proof of income: o Pay stubs o Employment letter with pay rate and weekly hours o Tax return o Unemployment documentation o Social Security o DCF documentation o Child support documentation

 My financial aid will only be finalized after being contacted by an Extended Learning staff member. Number of children living at Number of adults at home Gross monthly income: home: dependent on family income: Parent/Guardian Name:

Date:

Parent/Guardian Signature: If you would like this information translated into Spanish, Haitian Creole or Chinese, please contact Sheila Osko: 860 823 4205, x 2109. Si austed le gustaríaestainformaciόntraducida al español, criollohaitiano o chino, sírvasecontactar a Sheila Osko: 860 823 4205, x2109. Si ou ta renmenenfomasyonsatradui an Español, KreyόlAyisyenoubyenChinwa, tanprikontakte Sheila Osko: 860 823 4205, x 2109. 如果您想这些资料翻译成西班牙文，海地语或中文，请联系Sheila Osko: 860 823 4205, x 2109.