Paul Robeson freedom school Camp 2013 Registration Form

*Due with $50 deposit (counted toward Week 1 cost)

Childs Name: ____________________________________________ Age & Date of Birth: ________________________________ Grade in Sept. 2013: ____________ Childs Address (street, apt. #, city, state and zip):
_______________________________________ _______________________________________ _______________________________________

Mother/Guardians name:____________________________________________________________ Mothers Address (if different than childs): _______________________________________________ Best way to contact you (please circle): Home ph Cell ph Work ph Email Home ph.#: ____________________________ Cell ph.#: __________________________________ Email: ____________________________________________________________________________ Work name and address: ___________________________________________________________ Work ph.#: _____________________________ Father/Guardians name: ___________________________________________________________ Fathers Address (if different than childs): ______________________________________________ Best way to contact you (please circle): Home ph Cell ph Work ph Email Home ph.#: ____________________________ Cell ph.#: _________________________________ Email: ___________________________________________________________________________ Work name and address: ___________________________________________________________ Work ph.#: _____________________________ Emergency contact 1: _______________________________ Ph#:_____________________ Emergency contact 2: _______________________________ Ph#:_____________________ Walking permission: My child is allowed to walk home.
(please circle) Yes No

The following individuals are authorized to pick up my child: _________________________________________________________________________________ _________________________________________________________________________________

Childs doctor: _____________________________________ Ph#:__________________________ Doctors address:_________________________________________________________________ Allergies (including foods): __________________________________________________________ Medications the child is taking:_____________________________________________________ Health issues and/or activity restrictions:______________________________________________

Please check the boxes that apply:

My child is in good physical health and can participate in the normal activities of the program. My childs immunizations are up-to-date and are on le with the childs school.
Weeks of camp: Children are required to attend at least three of the four weeks of camp. Please indicate which weeks your child will attend:

Week 1: July 8--July 11 Week 2: July 15--July 18 Week 3: July 22--July 25 Week 4: July 29- August 1

Scholarship assistance is available. Please check the box below if you would like to inquire about this. Proof of need will be requested

Parent/Guardian Permission Drop off and pick up I give my child permission to attend Paul Robeson Freedom school, Mondays-Thursday, July 8th-August 1nd. I understand that transportation is not provided and that children are to arrive no earlier than 9AM am and to be picked up at 4:00pm. I understand that my child will not be released to anyone other than the persons listed as authorized to pick up. Students will be dismissed promptly at 4:00pm and should be picked up on time. Field trips I understand that one or two days per week, children will attend a field trip. Parents will be notified with details on each trip during the week. I understand that my signature on this permission slip allows my child to attend the field trips. Should I choose not to allow my child to attend a field trip, I will inform Paul Robeson Freedom school staff and keep my child home on that day. Photos Paul Robeson freedom school occasionally takes pictures/videos of its programs and children. I give Paul Robeson freedom school permission to use these photographs or videos in its website or promotional materials such as brochures and flyers. If this is unacceptable, please submit a written letter stating your wishes for your childs photograph/video not to be used. Cost The weekly rate is $50 per child, cash or money order. Payment is due for Week 1 at time of registration, for Week 2 on July 15, for Week 3 on July 22 and for Week 4 on July 29. Behavior expectations I have read the behavior expectations and the discipline policy and agree to these expectations. Medical authorization In the event that I cannot be reached during an emergency situation, I authorize Paul Robeson freedom school staff to make emergency medical decisions on my behalf. Parent/guardian signature: ______________________________________ Date:__________________

PAUL ROBESON FREEDOM SCHOOL Summer Camp 2013 Information

Please keep this sheet for your records

PRFS is located 520 CLINTON AVE BROOKLYN NY. Ph.#:

Email: JOIN@paulrobesonfreedomschool.org Website: www.paulrobesonfreedomschool.org

Dates of Program: ! Week 1: July 8--July 11 (Monday Thursday ! Week 2: July 15--July 18 (Monday Thursday ! Week 3: July 22--July 25 (Monday Thursday ! Week 4: July 29-August 1 (Monday Thursday Week 5: Aug 5th to Aug 8th Monday - Thursday Week 6th Aug 12TH To Aug 15TH Week 7 Aug 19th to 22nd Week 8 Aug 26th to Aug 29th Hours of Program: ! 9;00am 4:00pm ! If you are picking up your child from school, please be timely. Cost: $50 per child, per week. Cash or money order. Payment is due for Week 1 at time of registration, for Week 2 on July 15, for Week 3 on July 22 and for Week 4 on July 29.

Behavior Expectations/Discipline Policy We have a warm and loving environment at Paul Robeson Freedom and expect children to be respectful to staff and peers. Students will be supervised at all times. However, if any private bullying should occur, please advise your child to immediately alert a staff member about this, as well as any other kind of problem that may arise. In order to maintain a safe environment, we use the following discipline policy. The consequences for misbehavior are as follows: 1. First incident Verbal warning from teen or adult staff.* 2. Second incident Time out in foyer, while meeting with adult staff to discuss the problem.* 3. Third incident Time out in foyer, accompanied by a call home to parent or guardian. 4. Fourth incident Suspension for a period of days to be decided by the Summer Camp Director. 5. Continued incidents Removal from program. *If the incident is serious enough, a staff member may proceed directly to Step 3 and/or 4 (particularly if the childs behavior endangers him/herself or others).