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