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 #
Sex: Male ___ Female ____	Age	Date of Birth			Camp STAFF enter Student ID #
Street Address:		City			State/Zip
Home Telephone Number:
PARENT/GUARDIAN (1)
First Name:		Last Name:			Phone No. (If different above)
Employer:		City/State:			Phone No.
PARENT/GUARDIAN (2)
First Name:		Last Name:			Phone No. (If different above)
Employer:		City/State:			Phone No.
EMERGENCY CONTACT:				Phone No.
Two parents ___ One parent ___ Foster Family ___			Place of residence: Greenwood ____ Leflore County ____ Other (please indicate) ____________________
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
Is your home? ___Rented ___Owned			Number of years in the community _______
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): ________________________ - ____________________________
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 ___________________

“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