THE CENTER FOR INTERNATIONAL LOVE,
PEACE, AND UNITY CORPORATION
K-12 International Scientifically Research-based Summer Reading Camp
Orlando, Florida 32802-2811
APPLICATION
OUTREACH
LOCATION (Office
use) |
TODAY’S DATE: ____________________ CHILD’S GRADE AS OF MAY___________
KINDERGARTEN _____ PRE-K _____
First Name: (Child) |
Middle Initial |
Last Name: (Child) |
Social Security # |
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Sex: Male ___ Female ____ |
Age |
Date of Birth |
Camp STAFF enter Student ID # |
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Street Address: |
City |
State/Zip |
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Home Telephone Number: |
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PARENT/GUARDIAN (1) |
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First Name: |
Last Name: |
Phone No. (If different above) |
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Employer: |
City/State: |
Phone No. |
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PARENT/GUARDIAN (2) |
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First Name: |
Last Name: |
Phone No. (If different above) |
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Employer: |
City/State: |
Phone No. |
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EMERGENCY CONTACT: |
Phone No. |
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Two parents ___ One parent ___ Foster Family ___ |
Place of residence: Greenwood ____ Leflore County ____ Other (please indicate) ____________________ |
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Ethnic Origin: ___Black ___Native American ___Hispanic ___White ____Other |
Household Income: ___ $0 – 13,999 ___$40,000 – 54,999 ___$14,000 – 24,999 ___$55,000 – 74,999 ___$25,000 – 39,999 ___$75,000 – Over |
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Is your home? ___Rented ___Owned |
Number of years in the community _______ |
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Have you (person enrolling) participated in other research-based Reading Programs? ____ Yes ____ No If yes, please indicate program(s): ____________________________ What year? _______________________________ Has any member of your family participated in other research-based Reading Programs? ___ Yes ___ No If yes, please indicate family member and program(s): ________________________ - ____________________________ |
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How
did you hear about the Research-based Reading Camp? Check all that apply: ____Friend ___Mailed Brochure ___Volunteer ___TV/Radio/Newspaper ____Billboard ___Yellow Pages ___Camp Flyer ___Other ___________________ |
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“WHERE FUN!! MEETS
LEARNING AT THE NEXT ACADEMIC LEVEL(S)”
Medical Release
and History Health Statement: (to be completed by Parent/Guardian and/or Medical Doctor). YES responses will require an explanation. YES NO · Respiratory problems – asthma, persistent cough, etc. ___ ___ · Heart problems – high/low blood pressure, chest pain, etc. ___ ___ · Kidney, stomach, gall bladder or liver problems ___ ___ · Diabetes, hypoglycemia ___ ___ · Recent fractures, illness, exposure to contagious disease, etc. ___ ___ · Eye, ear, nose or throat problems – skin disease ___ ___ · Allergies – bee stings, ant bites, plants, sun, food, penicillin, etc. ___ ___ · Nervous disorders – epilepsy, convulsions, dizziness, etc. ___ ___ · Emotional disorders – frequent anxiety, excessive fears, etc. ___ ___ · Any hospitalization in the last two years? ___ ___ · Do you have any physically limiting conditions? ___ ___ · Do you currently take medication? ___ ___ · The participant WILL be bringing medication to program and activities ___ ___ Explanations: ___________________________________________________________________ ______________________________________________________________________________ Emergency Medical Treatment: I understand that every effort will be made to contact the parent(s) or guardian(s) of participants. If this is not possible, I hereby, authorize The Center for International Love, Peace, and Unity Corporation to obtain medical treatment. Parent/Guardian Signature _________________________________Daytime Phone ________________ Family Physician/Clinic _____________________________________Location _____________________ Phone ___________________ Insurance Company _______________________ Policy # ____________ Authorization to
remove child from this camp: SECRET
CODE: ________________________________ Father: YES ___ NO ___ Mother: YES ___ NO ___ (If no code, child will remain with Camp Director) Other: Name _______________________ ______Relationship _________________Phone # ______________________ Other: Name
_____________________________ Relationship _________________ Phone # _____________________ |
IMPORTANT NOTE: Please notify us immediately if there is a change in child’s pickup – secret
code and description must be given.
WAIVER
I hereby state that I/my child
are physically and mentally capable of safe participation in The Center for
International Love, Peace, and Unity Corporation (LPU) activities. I understand and expressly acknowledge that I
release The Center for International LPU Corporation and its staff from all
liability for any injury, loss or damage connected in any way to me/my child
participation in the Center for International LPU Corporation activities,
whether on or off The Center for International LPU Corporation premises. I also authorize The Center for International
LPU Corporation to obtain medical treatment for me/my child in the event of an
emergency. I give my permission to The
Center for International LPU Corporation to use, without limitation or
obligation, photographs, film footage, or tape recording in which may include me/my child’s image or voice for the
purposes of promoting or interpreting The Center for International LPU
Corporation educational programs.
I hereby give my permission
for my child ________________________________________ to be transported during
the camp
to and from any scheduled field trips.
Participant Signature: _________________________________________________________
Date: _________________________
Parent/Guardian Signature:
_____________________________________________________ Date: ________________________
The Center for International Love, Peace, and Unity
Corporation
K-12 International Research-based Summer Reading Camp