2023 Science Through ART

Summer Enrichment Program

Child’s Full Name: ______________________________________    Date of Birth: ____________

Child’s Grade in September 2023: ____________________  Child’s Gender/Age: __________

Telephone Numbers: Home:__________________________ Cell:_________________________ 

Language(s) Used in Home: ________________________ T-shirt size: _____________

School Attending: ________________________     School Principal: _______________________ 

Family Data

Parent/Guardian 1                                                           Parent/Guardian 2

Name: __________________________________ Name: _______________________________

Address: _______________________________   Address (if different): ____________________

______________________________________    ______________________________________

Cell Number: ___________________________ Cell Number: ____________________________   Email: ________________________________      Email: ________________________________ 

Occupation: _____________________________  Occupation: ___________________________

Employer: ______________________________   Employer: _____________________________

Please select the week(s) in which you are interested in enrolling your child:

Week 1: July 31- Aug 4             _______ 

Week 2: Aug 7 – 11                    _______ 

Week 3: Aug 14 – 18                  _______ 

Week 4: Aug 21 – 25                  _______

Please sign if you will allow us to use your child’s photograph for advertising purposes including social media (no names included):

____________________________________________   ________________________________

              (Signature)                                                             (Date)

The form below MUST be fully completed and signed or we will not able to register your child.

 Emergency Treatment Authorization Form

Name of Student: ___________________________________________   Date of Birth: ______________

I, (We), being the parent(s) or legal guardian(s) of the above named child, hereby appoint: 

Heather Christy-Robinson                         607-765-6590

Director, ScienceThroughART                                                     Phone number

to act in my/our behalf in authorizing medical, dental, or surgical care and hospitalization for the above named child in the event that I/we cannot be reached.

This document will be presented to a physician, dentist, or appropriate hospital representative at such time as any emergency medical, dental, or surgical care or hospitalization may be required.

Insurance Information: 

Name of Insurance Company: _____________________________________________________ I.D. or Contract Number: _________________________________________________________

Child’s Doctor: ______________________________________        _____________________________​                               

                            Name                                                                                        Phone number 

Medical Information:

Known Allergies: ________________________________________________________________ Has all compulsory immunizations to attend public school: ___ Yes  ___ No: If no, please list any administered: __________________________________________________________________ Has Measles immunization:  ___ Yes  ___ No

Medication Taken on a Regular Basis: _______________________________________________

Any Special Physical or Health Conditions: ___________________________________________

Cell Phone Numbers of Parent(s): Parent 1: _________________ Parent 2__________________

__________________________________________________            _____________________________

Signature                                                                                                          Date

(Optional)

In an attempt to help your child improve skills during our enrichment camp, please ask his/her teacher to complete the following form and return it to us on or before the first day of the program.

Student’s Name: ________________________________________    Present Grade:____ ___________

Teacher’s Name: ________________________________________  School: ______________________

Contact Information for teacher: (email or phone number):___________________________________ Dear Teacher,

The child named above will be participating in the Science Through ART program at the Balmville Grange.  Since you have been working with this child during the academic year, you can provide us with some very helpful information by taking a few minutes to complete the form below and returning it to his/her parents.  This information will enable us to best meet this student’s developmental needs as we incorporate enrichment opportunities into our fun activities.  Thank you!  If you have any questions, you can call Heather Christy-Robinson at 845-787-4248. (Interested in a bit of summer fun?  Contact me!)

Please circle any areas of concern.	Place a check in the appropriate box.
Above Grade Level	On Grade Level	Below Grade Level
Reading	Comprehension
Phonics/Word ID
Math	Concepts/Application
Computation
Writing	Expression
Mechanics
Organization
Please use the space below to provide any additional information you believe will help us support this child’s academic needs.

FOR PARENTS/GUARDIANS

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-toperson contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. 

The ScienceThroughART Program (S.T.ART) has put in place preventative measures to reduce the spread of COVID-19; however, S.T.ART cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending S.T.ART could increase your risk and your child(ren)’s risk of contracting COVID-19. 

——————————————————————————————————————————————

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending S.T.ART and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at S.T.ART may result from the actions, omissions, or negligence of myself and others, including, but not limited to, S.T.ART employees, volunteers, and program participants and their families.  

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any exposure or infection by Covid-19 to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at S.T.ART or participation in S.T.ART programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless S.T.ART, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of S.T.ART, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any S.T.ART program.