Summer Enrichment Registration Request Form

Summer Enrichment Program Registration Request Form
Thank you for your interest in our Summer Enrichment Program! Submitting this form authorizes our office to register and bill the parent/guardian of the individual listed on this form for the specified non-credit course(s). If additional information is needed for us to register a student for a course, or if a class you selected is no longer accepting registrations, we will contact you as soon as possible. Please note:
- This form can only be used to register the individual whose information is listed below. Please submit your request and fill out the form again for any additional students you'd like to register.
- Tuition and fees will only be refunded if drop notification (written, phone or in-person) has been received by the Office of Continuing Education during normal business hours (8 a.m.-4 p.m., M-F) before 4 p.m. Friday, June 24, 2022. No refunds will be processed once the June 24 deadline has passed.
- For courses that use Google Classroom, we will require a parent or student email address that is not a K-12 school email, as many districts use Google and there are issues with accessing Google Classrooms courses in different domains.
- Students in Zoom classes must have access to the internet and enough bandwidth to support live video streaming. For students in need of a device, a limited number of devices will be available to borrow. Students who need one must request it at the time of registration.
Student's name: *

Legal First Name Middle Name Last Name
Student's birth date: *

Month Day Year
Student's Banner ID (if applicable):
Student's mailing address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Parent or guardian's email address *
example@example.com
(optional) Student's email address:
example@example.com
If your course(s) will use Google Classroom, which email address do you prefer to receive instructions on creating a Google Classroom account for Summer Enrichment? *

Parent's email address Student's email address
Name of school: *

Parent or guardian information: *

	Name	Home phone	Work phone	Cell phone	Email
Parent or guardian 1
Parent or guardian 2

(Optional) If you are taking a course on Zoom, will you need to borrow a device? Please note that the supply is limited; students can borrow these on a first-come, first-served basis:

Yes No
Grade entering in September 2022: *

4th grade 5th grade 6th grade 7th grade 8th grade 9th grade 10th grade

COVID-19 Policies

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Please note that policies related to COVID-19 vaccination, masking, health and safety are subject to change. At this time, COVID-19 vaccination is strongly encouraged for Summer Enrichment students.
(optional) If you would like to upload a picture of the student's COVID vaccination record/card, you can do so here:

Browse Files

Cancel of

T-Shirt Size

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Please select (adult) T-shirt size. One T-shirt will be given to each student on the last week of the program. *

S M L XL

Medical Release Form

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Student Name

If parents are not available in an emergency, notify: *

	Name	Relationship to Student	Home Phone	Other Phone
Emergency Contact 1
Emergency Contact 2

Please specify any and all of the following (if applicable):
Operations or serious injuries (include dates):
Medical condition(s):
Allergies (including food, medication, insect stings, etc.):
Special diet:
Activity restrictions:
Medication (name) and how it is given:
MEDICAL RELEASE AUTHORIZATION: The above named child has permission to engage in all prescribed SUNY Adirondack Youth Enrichment activities, except those activity restrictions noted above. By typing my name below, I certify that I am the legal parent and/or have the legal ability to sign this authorization form on behalf of the above named child. In the event of illness or accident, I hereby authorize and consent to the administration of all medical and/or surgical treatment(s) to my child by a licensed physician or hospital in the event I am not able to consult with the attending physician(s), attempts to contact me have been unsuccessful, and the attending physician(s) deem(s) it advisable to proceed with such treatment(s). *

Media Release Form

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A: MEDIA RELEASE: Student has permission for SUNY Adirondack to photograph or videotape student for publications, media use and instructional purposes during this class. *

Yes No
B. COMPUTER/INTERNET USAGE: Some programs require computer and Internet use. If applicable, my child has permission to do so in a supervised environment and will abide by the guidelines below. *

Yes No
GUIDELINES:
1. All students must have permission from their parent/guardian to access the internet.
2. Respect for school equipment and its network is a condition of use of the computers.
3. Students are to notify the teacher immediately of any disturbing material they may encounter on the internet.
4. Students are not to give out personal information such as telephone numbers, full name, address, etc., to anyone on the internet.
5. Students are to never give anyone their password to any of their accounts or allow another student to use their account to access the internet or school network.
6. Students must gain clearance from the teacher before downloading any programs from the internet.
7. The teacher must first scan all media devices brought to the lab to be used in the computers for viruses.
8. Violation of any of these rules may result in forfeiture of permission to use the internet and school network and/or appropriate disciplinary action.

Submit Your Registration Request

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IMPORTANT - Please read the following, then click the "Submit" button below to submit your registration request. Contact the Office of Continuing Education at 518-743-2238 or conted@sunyacc.edu with any questions.
- The information submitted in this form will be used by Continuing Education staff to register the individual listed on this form for the course(s) specified.
- Once you have been officially signed up for the class in the College’s registration system, Continuing Education staff will send you a confirmation by email or phone, as well as send a hard copy of the confirmation and bill to your mailing address.
- If a course is full and unable to take additional registrations, or if we need to clarify additional details to finalize your registration, we will contact you by phone and/or email as soon as possible.
Please note that you will be automatically billed via mail for the course(s) once your registration has occurred.
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Summer Enrichment Program Registration Request Form

Course Selection: Grades 4-6

Course Selection: Grades 7-10

COVID-19 Policies

T-Shirt Size

Medical Release Form

Media Release Form

Submit Your Registration Request