General Public Summer Program 2024 Application

Eliot-Pearson Children's School Summer Program 2024 Application

Please submit your application by January 31, 2024
The Eliot-Pearson Children’s School offers a six-week Summer Program for children ages 4 to 7 years old.

Session 1: Monday, June 24th 2024 - Friday, July 12th 2024

Session 2: Monday, July 15th 2024 - Friday, August 2nd 2024

Half Day: 8:30AM - 12:30PM

Full Day: 8:30AM - 4:00PM
Summer Tuition Summary
Child's Information
Child's Name*

First NameMiddle NameLast Name
Child's Birth Date*

MonthDayYear
First Day of Summer Camp

MonthDayYear
Date
Age of Child 06/24/2024
Child's Gender*
Child's Primary Language*
Please list any additional languages your child speaks.
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Eliot-Pearson Children's School connections (select all that apply)

My child is a former studentMy child is the sibling of a current studentMy child is the sibling of a former studentOther
If other, please explain

Parent/Caregiver 1's Information
Parent/Caregiver 1's Name*

First NameLast Name
Relationship to child*
Email Address*
example@example.com
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number*
Please enter a valid phone number.

Parent/Caregiver 2's Information
First NameLast Name
Relationship to child*
Email Address*
example@example.com
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Home Address, if different from child's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Summer Tuition Summary
Please select the sessions you would like your child to attend (you may choose both)*

Session 1: Monday, June 24th 2024 - Friday, July 12th 2024Session 2: Monday, July 15th 2024 - Friday, August 2nd 2024
Please select the time you would like your child to attend Session 1

Session 1: Half Day 8:30 AM - 12:30 PMSession 1: Full Day: 8:30 AM - 4:00 PM
Please Select the time you would like your child to attend Session 2

Session 2: Half Day 8:30 AM - 12:30 PMSession 2: Full Day 8:30 AM - 4:00 PM

Help us get to know your child

Please use these this section to introduce us to your child.
Help us understand your child. Please share your child’s personality, temperament, characteristics and/or interests.*
Please list your child’s previous group experiences, include schools, play groups, weekend activities, or any other group setting)*

Eliot-Pearson Children's School: Summer Program
How did you hear about Eliot-Pearson Children’s School? Please indicate where (name or publication)

Health Summary

Tell us about your child's medical history. Please upload any relevant documents.
Tell us about your child’s health. Has your child had any major health/developmental complications or challenges? Please share specifics: vision, hearing, walking, speaking, or attention? Other?
Has your child ever been evaluated or screened?

YesNo
If yes, please share more information
Does your child have any medical conditions or allergies you would like us to aware of?
Does your child require medication to be kept at school (medication, epipen, inhaler etc.)

YesNoUnsure
Has your child received the Covid-19 Vaccine?

YesNo
Please upload any relevant health documentation.

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PRESCRIPTION MEDICATION - FOR YOUR INFORMATION

YOU DO NOT NEED TO FILL OUT THESE FORMS RIGHT NOW, THIS IS SIMPLY SO YOU UNDERSTAND OUR POLICIES ABOUT KEEPING MEDICATION AT EPCS

If your child requires Prescribed Medication at school, they will need the three things below

1. Medical Consent Form
- Authorizes school to administer medicine.
- Every medication (both prescription and non-prescription) requires a medication consent form!
- The form must be signed by parents AND doctor.
- The consent form will include which staff member the parent trained to administer medicine.
- Valid for 1 year after Physician signature date
Click Here to Download a Medical Consent Form

2. Individualized Healthcare Plan (IHCP)
- An individualized Healthcare Plan informs the school on how and when to administer medication.
- An IHCP is typically created by the doctor.
- Parent Signature AND doctor signature required on IHCP.
- If there is more than one medication on your IHCP all of them require a medical consent form!
- Valid for 1 year after Physician signature
Click Here to Download a Individualized Healthcare Plan Form

*In most cases the Individualized Healthcare plan will be provided by Child's Physician. Check that the Healthcare Plan answers all the questions on the linked form.

3. Medication
- Medicine is in the original box and with original label from pharmacy
  pharmacy side effects sheet (typically stapled to bag at pharmacy) is required to be kept with the medicine.
- Prescribed Child's name must be on the pharmacy label on the box.
- The check two expiration dates on the medicine!
  - The Prescription must be valid (check the “discard after” date on the pharmacy label).
  - The medicine must be valid (check expiration date on box itself)
Please upload any relevant health documentation.

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NON-PRESCRIPTION MEDICATION - FOR YOUR INFORMATION

YOU DO NOT NEED TO FILL OUT THESE FORMS RIGHT NOW, THIS IS SIMPLY SO YOU UNDERSTAND OUR POLICIES ABOUT KEEPING MEDICATION AT EPCS

If your child requires over the counter Medication at school, they will need the three things below

1. Medical Consent Form
- Authorizes school to administer medicine.
- Every medication (both prescription and non-prescription) requires a medication consent form!
- The form must be signed by parents AND doctor.
- The consent form will include which staff member the parent trained to administer medicine.
- Valid for 1 year after Physician signature date
Click Here to Download a Medical Consent Form

3. Medication
- Medicine is in the original box
- The check the expiration date on the medicine!
Please upload any relevant health documentation.

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Demographic Information

We offer you the option to share the following information with us. No individual family selections are made based on this information. There will be no impact on your application based on your answers.
Racial Identity
Ethnic/Cultural Identity
National Origin
Religious Identity
Select ALL applicable identities

LGBTQIA+Single ParentAdopted FamilyBlended FamilyFoster Family
Other Identities

Please check all the boxes and sign below*

I request admissions for my child to attend the Eliot-Pearson Children's School 2023 Summer ProgramI understand that this contract obligates me for the FULL tuition cost, and I am aware that there will be NO REFUNDS OR CREDITS FOR WITHDRAWAL OR ABSENCES.I agree to pay the Full Summer Program tuition by May 10th, 2023I understand that the last day of the Summer Program Session 2 (July 28th, 2023) ends at 12:30pm for everyoneI understand that the program will be closed on Monday, June 19th and Tuesday, July 4th in observance of Juneteenth and Independence DayI understand that placements in specific classes cannot be guaranteed
My signature indicates my understanding and agreement with the above statements.*

Clear

Payment
Please press submit to complete your summer program application and pay the $200 enrollment deposit.

If your child is not accepted to the program your deposit will be refunded. If your child is accepted it will be credited towards your tuition. Please submit this payment by January 31, 2024.
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Eliot-Pearson Children's School Summer Program 2024 Application

The Eliot-Pearson Children’s School offers a six-week Summer Program for children ages 4 to 7 years old.

Session 1: Monday, June 24th 2024 - Friday, July 12th 2024

Session 2: Monday, July 15th 2024 - Friday, August 2nd 2024

Half Day: 8:30AM - 12:30PM

Full Day: 8:30AM - 4:00PM

Child's Information

Parent/Caregiver 1's Information

Parent/Caregiver 2's Information

Help us get to know your child

Eliot-Pearson Children's School: Summer Program

Health Summary

PRESCRIPTION MEDICATION - FOR YOUR INFORMATION

NON-PRESCRIPTION MEDICATION - FOR YOUR INFORMATION

Demographic Information

Payment