5151
Park Ave. Fairfield, CT 06825 (203) 325-4470
RE-ENROLLMENT FOR CURRENT FAMILIES
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.
COMPLETED RE-ENROLLMENT FORMS ARE DUE the January
31st. StudentŐs forms submitted after this date are not guaranteed re-entry into the program.
STUDENT INFORMATION (only one child
per form, please print):
Full
Name:
___________________________________________________________________________________
First Middle Last Preferred
Nickname
Home
Address:
________________________________________________________________________________________
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)
Language
Information
ApplicantŐs primary language _______________________________
Language spoken at applicantŐs home _________________________
FAMILY INFORMATION:
Student lives with: (check any that apply)
o Father and Mother
o Mother
o Father
o Stepmother/father ______________________________________
Name
o Other ______________________________________
Name
In the case of
divorce, separation or other family circumstance, please describes the childŐs
living situation (i.e. child spends ½ week with one parent and ½
week with the other parent):
Name of
Parent/Guardian I:
__________________________________________________________________________________________
First Middle
Last
Home
Address:
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: _________________________________________________________________________________________
Emergency Contact:
________________________________________________________________________________ Name Relationship
to student
___________________________________________________________________________________
Phone # Cell
#
Household Information:
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:
____________
Household Income:
Includes all family members living in the household. (Gross income before
taxes are withheld:
Yearly $_____________ OR Monthly
$____________
OR Weekly $__________
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)
|
X-Small
(Youth) |
Small
(Youth) |
Medium
(Youth) |
Large
(Youth) |
X-Large
(Youth) |
XX-Large
(Youth) |
|
X-Small
(Adult) |
Small
(Adult) |
Medium
(Adult) |
Large
(Adult) |
X-Large
(Adult) |
XX-Large
(Adult) |
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)
Arrival:_________________________
Dismissal:_______________________
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)
_________________________________________
_________________________________________
_________________________________________
Medical
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)
Yes No
If yes, please list the
acceptable OTC medications.
____________________________________________________________________________
StudentŐs
Doctor or Clinic Information (Optional)
Name: __________________________________________
Address: ________________________________________
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:
__________________________
Additional
Questions
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:
______________________________________________________________________
RE-ENROLLMENT CHECKLIST
Fully completed Re-Enrollment
form ______
Report card for last
marking period ______
$30 enrollment fee per
student ($10 for each additional sibling) _______
RE-ENROLLMENT DEADLINE: January
31st, 2020
Mail Re-Enrollment
Materials to:
Horizons
at Sacred Heart University
5151
Park Ave.
Fairfield,
CT 06825
Or
Email to horizons@sacredheart.edu