Language
English (US)
Spanish (Latin America)
2018 Summer Program Application
Student Information
Student Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date Picker Icon
What grade is your child currently in?
*
Kindergarten
1st
2nd
3rd
4th
Gender
*
Female
Male
Ethnicity
*
Black
White
Hispanic
Asian
Other
Home Language
*
English
Spanish
Arabic
French
Other
T-Shirt Size (Child)
*
S
M
L
XL
Other
Parent/Guardian Info
Name of Parent/Guardian Registering Child
*
First Name
Last Name
Cell Phone
*
Home Phone
Work Phone
Personal E-mail
T-Shirt Size (Adult)
*
S
M
L
XL
XXL
3XL
2nd Parent/Guardian
*
First Name
Last Name
Cell Phone
*
Home Phone
Work Phone
Personal E-mail
T-Shirt Size (Adult)
S
M
L
XL
XXL
3XL
Pickup Authorization & Emergency Contacts
Authorized Contact #1
*
First Name
Last Name
*
Relation to student
*
Cell Phone
Home Phone
Work Phone
Authorized Contact #2
*
First Name
Last Name
*
Relation to student
*
Cell Phone
Home Phone
Work Phone
Home Visit
What time of the day are you most available for a home visit?
Morning
Afternoon
Evening
What days are you most available for a home visit?
Monday
Tuesday
Wednesday
Thursday
Friday
Other notes to help your teacher schedule a home visit
Afternoon Programming
What afternoon activities/enrichments would you like your child involved in?
Sports
Arts-based
Science & Technology
Other
Medical Information
Does your child have any allergies or will he/she need to take any medication during the program?
I understand that in the event of an emergency affecting my child while participating in the GCCS Summer Program, a designated GCCS employee will attempt to contact me and inform me as soon as possible. In the event I cannot be reached, I authorize GCCS summer program staff to furnish and/or obtain emergency medical treatment which may be necessary for my child during program times.
Parent Initials
Student Self-Dismissal
I give GCCS Summer Program staff permission to release my child from the GCCS Summer School program without supervision. I understand that my child will be responsible for walking home or taking public transportation home himself/herself. As parent/guardian, I hereby release and discharge Global Community Charter School and Springboard Collective and their officers, employees, agents, and volunteers from all claims for injury, illness, death, loss or damage as a result of the release of my child, without supervision.
*
Yes
No
Summer Program Releases
I give permission for any photograph, image, voice, video, or other recording, in all forms, and the first name of my child to be published and distributed in any media for promotional or informational purposes in connection with Global Community Charter School and Springboard Collaborative.
*
Parent Initials
I authorize Global Community Charter School to share with Springboard Collaborative the following additional information contained in my child's records: student's ongoing reading level, ethnicity, IEP status, and Free and Reduced Lunch Plan eligibility.
*
Parent Initials
Parent Release
I understand the nature of the Global Community Charter School (GCCS) Springboard Collaborative program and that participation is voluntary. I understand that neither GCCS nor Springboard Collaborative are responsible for loss, damage, illness, or injury to person or property as a result of participation in the program. I hereby release and discharge GCCS and Springboard Collaborative and their officers, employees, agents, and volunteers from any and all claims for injury, illness, death, loss or damage as a result of summer program activities. I also hereby grant permission for my child to leave GCCS Summer Camp premises, under proper supervision of GCCS staff, for neighborhood walks, park activities and field trips. It is my understanding that these trips will be taken over the camp session without further consent from me.
*
Parent Initials
Parent/Caregiver Signature
To secure your child's spot, submit a deposit with Registration. If paying with check, make it payable to Global Community Charter School. Pay $400 by June 1st to save $100!
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GCCS Summer Camp Registration Deposit Amount of $50.00 suggested. Deposit is non-refundable.
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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