To register online, click here:

To access the Registration materials, click here:

or print the following and mail to

Mailing address: 3 Hideaway Lane, Newburgh, NY 12550:

Science Through A R T

Summer Enrichment Program

Child’s Full Name:

Date of Birth:

Address

Child’s Grade in September 2022:

Child’s Gender:

T-shirt size (see sizing chart): XS (2-4),  S (6-8), M (10-12), L (14-16), XL (18-20)

Telephone Numbers: Home:

Cell:

Language Used in Home:

Current School Grade:

School Attending:

School Principal:

Family Data

Parent(s)/Guardian(s)                                                       

Name(s):

Address(es):

Email:

Occupation:

Employer:

Business Address:

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

Week 1: Aug 1-5                   _______ (Monday – Friday)

Week 2: Aug 8 – Aug 12     _______  (Monday – Friday)

Week 3: Aug 15 – 19               _______ (Monday – Friday)

Week 4: Aug 22 – 26             _______ (Monday – Friday)

Please sign if you will allow us to use your child’s photograph for advertising purposes, including on 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:

Name: Heather Christy-Robinson             Phone number 845-787-4248 and 607-765-6590

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:                                Phone number

Medical Information:

Known Allergies:

Medication Taken on a Regular Basis:

Has all compulsory immunizations to attend public school: ___ Yes  ___ No: If no, please list any administered:

Any Special Physical or Health Conditions:

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.  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 (or you can visit  www.sciencethroughart.org and complete the form online). 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.

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.