5151 Park Ave. Fairfield, CT 06825 (203) 325-4470
New Student Application
á SUMMER PROGRAM - The Summer Program is a Kindergarten through 8th Grade 6-week enrichment program that begins June 29th and ends August 7th. We are closed July 3rd. Transportation is provided to from central locations. Students are on the SHU campus Monday - Friday from 8:00 am to 3:30 pm. The students participate in academics, art and music classes, sports, swimming lessons, and weekly field trips. We require that our students attend the entire summer session. Students are expected to return to Horizons every summer through the summer after 8th grade.
á SCHOOL YEAR PROGRAM - The School Year Program consists of ten Saturday Academies throughout the school year and attendance is required. These programs typically run from 8:30 am – 12:00 pm and transportation is provided.
STUDENT INFORMATION (only one child per form, please print):
First Middle Last Preferred Nickname
Street Apartment # City State Zip
Home Phone Number: _____________________Cell Phone Number: _________________________________
Date of Birth: ____/____/____ Gender (please circle one): M F Other
Mo / Day / Year
Current School: _________________________________________Current Grade: ______________________
Homeroom Teacher: ______________________________
Does applicant receive Special Education at current school? (circle one) Yes No
Does applicant have an IEP or 504 plan? (circle one). Yes No
If yes, please attach.
Is the applicant Hispanic or Latino? (circle one) Yes No
Please make the selection(s) that best describes the childŐs racial/ethnic background:
□ American Indian or Alaska Native (persons having origins in any of the original peoples of North America and maintain cultural identification through tribal affiliation or community recognition.)
□ Asian or Pacific Islander (Persons having origins in any of the original peoples of the Far East, Southeast Asia, the Pacific Islands or the Indian subcontinent. This area includes China, India, Japan, Korea, Philippine Islands and Samoa).
□ Hispanic (persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin—regardless of race)
□ Black or African American (Persons having origins in any of the Black racial groups of Africa)
□ White or Caucasian (Persons having origins in any of the original peoples of Europe, North Africa or the Middle East)
ApplicantŐs primary language _______________________________
Language spoken at applicantŐs home _________________________
Student lives with: (check any that apply)
o Father and Mother
o Stepmother/father ______________________________________
o Other ______________________________________
Name of Parent/Guardian I:
First Middle Last
Street Apartment # City State Zip
Home Phone Number: ____________________Cell Phone Number: ________________________________
Employer / Company: __________________________Occupation: _________________________________
Work phone number: __________________________
Preferred Email: _______________________________________________________________________________________
Name of Parent/Guardian II:
First Middle Last
Home Address (if different from Parent/Guardian I):
_______________________________________________________________________________________ Street Apartment # City State Zip
Home Phone Number: _______________________ Cell Phone Number: ___________________________
Employer / Company: __________________________ Occupation: _______________________________
Work phone number: _________________________
Preferred Email: _________________________________________________________________________________________
________________________________________________________________________________ Name Relationship to student
Phone # Cell #
Please list all other household members, for siblings, include date of birth and age:
Total number of children in household: __________
Total number of adults in household: ____________
Includes all family members living in the household. (Gross income before
taxes are withheld:
Yearly $_____________ OR Monthly
OR Weekly $__________
Household Income: Includes all family members living in the household. (Gross income before taxes are withheld:
What is the highest level of Education completed by the applicantŐs parent or guardian?
□ Some HS □ HS Diploma or equivalent □ Some College □ Associates
□ Bachelors □ Masters □ DoctorateŐs □ Other _________________
T-Shirt Size? (circle one)
Arrival and Dismissal
Please indicate how your child will arrive and depart to the program. Will they take the bus or will they be dropped off by a parent. If they are taking the bus, please indicate which bus stop ( Marin, Madison or St. Raphael)
Who has the privilege of picking up your child from Horizons at SHU? Please write their name, relationship and phone number of each person (maximum 3)
Does the applicant have any allergies or medical conditions? Yes No
If yes, please list: _____________________________________________________________
Please list any medications the applicant takes on a regular basis? ______________________
Can Horizons administer Over the Counter (OTC) medications to your child? (circle one)
If yes, please list the acceptable OTC medications. ____________________________________________________________________________
StudentŐs Doctor or Clinic Information (Optional)
Phone Number: ___________________________________
Insurance Information: _____________________________
If emergency treatment is required and the parent cannot be reached, may the school nurse or other official use their judgement in calling the doctor indicated above or call the ambulance service? Yes No
Relationship to Child: __________________________
What do you hope your child will gain from Horizons at SHU?
What activities does your child participate in?
What 3 words best describe your child?
What are your childŐs greatest strengths?
Has your child been retained (i.e.: repeated a grade)? If so, in what grade was repeated?
What situations does your child find challenging?
1. I give permission to my childŐs school to release the following annual school records to the Horizons at SHU: academic (grades), health, attendance, disciplinary, and psychological. I give permission to my childŐs school to release, and/or provide contact or forwarding information to the Horizons Student Enrichment Program for the purposes of contacting me and/or my child in the future. This permission to release information to Horizons about my child is to be in effect until the child graduates from high school. I am aware that I may review or challenge any records or information prior to release. All information and materials of any kind gathered during this process will be confidential and will not be disclosed to my child or my family.
2. I give permission to Horizons for my child to participate in and be transported to field trips, overnight camping, swimming, and other special events taking place during the summer program and year-round activities. I give permission for my child to take part in all program activities including academic and health assessment, and trips away from the school premises. Trips and activities may include, but are not limited to, rock climbing, bowling, visiting farms, visiting museums, visiting zoos, yoga, dance, gardening, soccer, basketball, golf, tennis, etc. I hereby release the Horizons at SHU and Sacred Heart University from liability to me or to my child for any loss or damage sustained by me or my child because of an injury to my child while at Horizons, during any HorizonsŐ activity, or while being transported to and from Horizons.
3. I authorize photos of my child that were taken during Horizons, quotes of my child, my childŐs art work, project work, writings, and photographs taken by my child to be reproduced for use in media, publications, and fundraising.
4. I give permission for my child to use the Internet at Horizons and hereby release the school from any associated liabilities.
5. I understand and agree with the Horizons ProgramŐs Attendance Policy: ŇIt is extremely important that children attend the program every day. You should not plan trips, doctorŐs appointments or anything else that would keep your child from attending all program days. If your child misses 2 days
or more because of non-medical emergencies, we will not invite him or her to return the following year and will give his or her place to another child. This policy will be strictly enforced.
6. I agree that if my childŐs transportation plans change for any reason, or if they will be picked up early, or by someone other than the guardian, I will provide the information in writing at least 24 hours in advance.
7. I agree to notify the Horizons office immediately if my family contact information changes, including phone numbers, address, email, or school changes.
Parent/Guardian Signature ____________________________________________Date:______________
PLEASE PRINT NAME: ______________________________________________________________________
Fully completed Application From ______
Teacher Evaluation Form____________
A copy of your childŐs most recent report card and last yearŐs report card (not required for new Kindergarten students_________
A copy of your childŐs IEP or 504 plan (if applicable)_______
Application DEADLINE: January 31st, 2020
Mail Re-Enrollment Materials to:
Horizons at Sacred Heart University
5151 Park Ave.
Fairfield, CT 06825
Or Email to email@example.com