subject_line
Arts of Success Summer Camp
STUDENT INFORMATION
Student Name
(Last, First, M.I.)
*
Date of Birth
*
+
Student ID #
*
Last Grade
*
K
1
2
3
4
5
Last School
*
CAE
CDN
EHE
ESE
JHE
MCE
MLK
PDS
RRE
SVE
VGE
Student Street Address
*
Student City
*
State
*
🛈
Student Zip
*
Student Phone 1
*
Student Phone 2
Shirt Size
*
Youth Small
Youth Medium
Youth Large
Youth X-Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Student Has
(check all that apply)
IEP
504
BIP
Week & Session Preference
Week 1 (6/6/22 - 6/10/22) AM (0 remaining)
Week 1 (6/6/22 - 6/10/22) PM (0 remaining)
Week 2 (6/13/22 - 6/17/22) AM (0 remaining)
Week 2 (6/13/22 - 6/17/22) PM (0 remaining)
The sign up is now full. Please sign up on
our
waitlist
to be contacted if slots become available. Thank you.
WaitList: Week & Session Preference
*
Week 1 (6/6/22 - 6/10/22) AM (0 remaining)
Week 1 (6/6/22 - 6/10/22) PM (7 remaining)
Week 2 (6/13/22 - 6/17/22) AM (6 remaining)
Week 2 (6/13/22 - 6/17/22) PM (2 remaining)
Waitlist is limited to one session only, please
do not
submit
multiple submissions per student. Thank you.
1st PARENT/GUARDIAN INFORMATION
Parent/Guardian's Full Name
*
Parent/Guardian's Email
*
RRPS Employee?
*
Yes
No
Parent/Guardian Street Address
*
Parent/Guardian City
*
State
*
🛈
Parent Zip
*
Parent/Guardian's Phone 1
*
Parent/Guardian's Phone 2
Parent/Guardian's Phone 3
Media Release Agreement
*
Yes, I give permission for my child to be recorded for school media purposes
No, I do not give permission for my child to be recorded for school media purposes
EMERGENCY INFORMATION
Emergency Contact Name
*
Relationship to Student
*
Emergency Contact Email
*
Emergency Contact Address
*
Emergency Contact Phone 1
*
Emergency Contact Phone 2
Emergency Contact Phone 3
form admin
only - test
y
n
IN CASE OF ILLNESS OR ACCIDENT, AND YOU CANNOT REACH ME, THE SCHOOL IS AUTHORIZED TO PROCEED AS INDICATED BELOW:
2nd Emergency Contact Name
2nd Emergency Contact Phone
IF UNABLE TO REACH ANYONE, PLEASE CONTACT MY PHYSICIAN & FOLLOW HIS/HER ORDERS.
Physician Phone
*
Hospital Preference
*
Dentist Name
*
Dentist Phone
*
Language spoken at home
*
My child has the following health problems
(example: allergy, asthma, kidneys, seizures, heart, etc.):
My child has the following dietary restrictions
(include food allergies and/or special diet considerations):