Summer Enrichment 2020 Registration Request Form

Summer Enrichment 2020 Registration Request Form
Please note: This form may only be used to register for SUNY Adirondack's 2020 online Summer Enrichment Program.

Thank you for your interest in Summer Enrichment. 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.
- 100% 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 (8am-4pm, M-F) prior to 4pm on Friday, June 19, 2020 . No refunds will be processed once the June 19 deadline has passed.
Student Name *

Legal First Name Middle Name Last Name
Birth Date *

Month Day Year
Student's Banner ID or SSN
Parent/Guardian's Email Address: *
example@example.com
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Name of school

Parent or guardian information *

Name

Home phone

Work phone

Cell phone

Parent or guardian 1

Parent or guardian 2

Grade entering in September 2020 *

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

Course Selection: Grades 4-6

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Please select the course(s) for which you would like to register.

Discover Minecraft Anatomy of a Comic The World of Harry Potter

Course Selection: Grades 7-10

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Please select the course(s) for which you would like to register.

Rockets & Crew Space Missions Meditative Art Robotics with VEX V5 Blocks Mystery Solved 2020

T-Shirt Size

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Please select (adult) t-shirt size. One t-shirt will be sent to each student by mail at the end of the program.

S M L XL

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 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 it advisable to proceed with such treatment(s). *
Parent/guardian name

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 that authorizes them access to the Internet.
2. Respect for school equipment and its network is a condition for 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 like 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. Details on how to pay course fees are available at: https://www.sunyacc.edu/continuing-ed/registration
Should be Empty:

Course Selection: Grades 4-6