Elite Summer Day Camp

Student name *

First Name

Last Name

Student Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does your student receive any of the following services?

504 Plan: A plan developed to accommodate an academic setting for a student's challenges/disabilities.

Title 1: Services provided to children who are failing, or at most risk of failing, to meet challenging State Academic Standards.

Special Education (EC): Exceptional Children with IEP's (Individualized Educational Plans) receive services and accommodations/modifications for their disability, or disabilities..

AIG (Academically or intellectually gifted): Students that show the potential to perform at a substantially high level of accomplishment when compared with others of their age, experiences, or environment.

ESL (English Second Language): Students that may receive services to support the development of English Language Skills.

None of the above.

My child needs after school for: *

Tutoring

Homework time

Enrichment activities

School work recovery

Which week of summer camp would your child be attending? *

Week 1: June 2 - June 6

Week 2: June 9 - June 13

Week 3: June 16 - June 20

Week 4: June 23 - June 27

Week 5: July 7 - July 11

Week 6: July 14 - July 18

Week 7: July 21 - July 25

Week 8: July 28 - August 1

Parent/Guardian Name: *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name #2:

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does your child have any medical conditions, allergies, and/or disabilities? If yes, fill out the form linked below.

Yes

No

Photo Permission *

I give permission for my child to be photographed while participating in the Higher Academia Programs.

I do not wish for my child to be photographed while participating in the Higher Academia Programs.

Website Permission *

I give permission for my child's photograph to be used on the Higher Academia website.

I do not wish for my child's photograph to be used on the Higher Academia website.

Observer Permission: *

I give permission for my child to interact with Higher Academia observers.

I do not wish for my child to interact with Higher Academia observers.

Student Records Permission/Release: *

Select at least 2.

I give permission for Higher Academia faculty and advisors to access my child's grades permitted by his/her school.

I do not wish for Higher Academia faculty and advisors to access my child's grades permitted by his/her school.

I give permission to discussions between my child's teachers and Higher Academia advisors about academic progress and necessary tutoring/training.

I do not wish for discussions between my child's teachers and Higher Academia advisors about academic progress and necessary tutoring/training.

Student Full Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY