May 17, 2013 - Telephone: (Home). (Work). T-Shirt Size (circle one) Children: M L. Adult: S M L XL. I am requesting that
Somerville Public Schools
51 West Cliff Street Somerville New Jersey 08876
(908) 218-4118 Fax: (908) 526-9668 E-mail:
[email protected] K ather i ne K . Ne ar y PreK-12 Supervisor
April 2013
Dear Parent/Guardian: Twelve years ago, we began a special summer program for all Somerville Middle School students entering grades 6 through 8 in September of the following year. I would like to invite your child to participate in the Summer Enrichment Academy for this upcoming year. Students are invited to participate in language arts literacy, drama, physical education, art, mathematics, and science activities. Each segment is created to challenge and enhance your child’s knowledge. Your child will participate in engaging activities related to “It’s a Small World” while incorporating language arts literacy, mathematics, and science skills. The dates for the program are July 8, 2013 to July 18, 2013. Sessions are held from 8:30 a.m. to 11:30 a.m. One extended day is planned. The program is partially supported by the district, as well as tuition fees. This summer, a fee of $50.00 is required for the program. If there is a need for financial assistance it will be provided by a benefactor to the district. Space is limited and registering your child in a timely fashion is very important. Therefore, if you wish to have your child participate in this summer program, please return all of the required application, emergency, and medical forms by Friday, May 17, 2013. To ensure registration, your payment of fifty dollars ($50.00) must be included with the required forms. Please submit a check or money order payable to the “Somerville Board of Education.” Thank you for your ongoing support of our schools and children. Sincerely,
Katherine K. Neary PreK-12 Supervisor of Humanities and Related Content Areas
Office of Curriculum and Instruction
SUMMER ENRICHMENT PROGRAM (2013): GRADES 6-8
“It’s a Small World” Somerville Middle School Enrichment Academy Grades 6-8 Students who will be in grades 6 through 8 in September 2013 are invited to participate in the Academy. Each segment of the Academy is created to challenge and enhance your child’s knowledge. Your child will participate in engaging activities related to “It’s a Small World” while incorporating language arts literacy, mathematics, social studies, and science activities. Location: Van Derveer Elementary School Dates: July 8, 2013 to July 18, 2013 (8 half days, 1 full day) Time: 8:30 a.m. to 11:30 a.m. Program cost: $50.00 Program cost will not be pro-rated. Check or money order payable to: Somerville Board of Education Financial assistance is available for students who demonstrate need. For information, please call (908) 218-4118
Enrollment is limited and is on a first come, first served basis. All forms enclosed must be returned to be considered for enrollment. Please return payment along with the attached application, emergency, and medical forms no later than Friday, May 17, 2013 to: Somerville Board of Education c/o Mrs. Katherine K. Neary 51 West Cliff Street Somerville, NJ 08876 Please note: Students may not participate in overlapping summer programs within the school district.
Office of Curriculum and Instruction
SOMERVILLE MIDDLE SCHOOL SUMMER ENRICHMENT ACADEMY (2013) GRADES 6-8 REGISTRATION FORM Please print or type using ink.
Student:
Grade (in September 2013): Last name
First name
Parent/Guardian: Last name
First name
Full Address: Telephone: (Home)
(Work)
T-Shirt Size (circle one) Children:
M
L
Adult:
S
M
L
XL
I am requesting that my child be considered for enrollment in the Somerville Middle School Enrichment Academy. Enclosed is: √ a check or money order for $50.00 payable to: Somerville Board of Education Parent/Guardian Signature
Date
Please mail your payment along with the application, emergency, and medical forms no later than Friday, May 17, 2013 to: Somerville Board of Education c/o Mrs. Katherine K. Neary 51 West Cliff Street Somerville, NJ 08876 Or have your child bring the forms with payment to the school’s main office.
Office use only:
Date received: __________ Check #
Office of Curriculum and Instruction
SOMERVILLE MIDDLE SCHOOL SUMMER ENRICHMENT ACADEMY (2013) GRADES 6-8 EMERGENCY FORM Dear Parent/Guardian: Please complete, by printing in ink, the information requested below so that we may better serve your child should an emergency arise. Student: ______________________________________ Date of Birth: ________ Grade (in Sept. 2013): _________ Last Name
First Name
Student’s Home Address:
Town:
PARENT/GUARDIAN INFORMATION: Mother/Guardian Name: ________________________
Place of Work/Address: __________________________ ______________________________________________
Home Address: _______________________________ ____________________________________________
Hours of Work: _______________ Return: ___________
Home Telephone: _____________________________
Work Telephone: _____________ Ext: ______________
Father/Guardian Name: _________________________
Place of Work/Address: __________________________ ______________________________________________
Home Address: _______________________________ ____________________________________________
Hours of Work: _______________ Return: ___________
Home Telephone: _____________________________
Work Telephone: _____________ Ext: ______________
EMERGENCY INFORMATION: Names of two persons willing to arrange for transportation and care of your child if you cannot be reached. Please inform person(s) of this. Name Address Telephone 1. 2. Doctor to notify in case of emergency:
My child will be going home: (Please check and complete) □ walking with □ ride with □ Other (please specify)
(parents MUST make own arrangements)
Parent/Guardian Signature:
Date: Please
complete the back of this form.
MEDICAL FORM Please print or type using ink. All information will be kept confidential. Student:
Grade (in September 2013): Last name
First name
1.
Is your child allergic to bee/wasp stings? Yes ___ No ___ If yes, please list treatment.
2.
Does your child have any allergies that would affect him/her at the program? Yes ___ No___ If yes, please list allergy and treatment.
3.
Does your child have any medical condition(s), such as asthma, seizures, etc.? Yes ___ No___ If yes, please list condition(s), symptoms, and treatment.
4.
Will your child need to receive medication during program hours? Yes ___ No___ If yes, please list medication(s) below.
Please supply your child’s medication in the actual prescription container/bottle, which should include your child’s full name and dosage information.
5.
Date of last tetanus shot:
. __________________
Parent/Guardian Signature Medication(s):
Date
