Brockport Summer Learning Program 2024

Location: First Unitarian Church of Rochester (220 S Winton Road Rochester, NY 14610)

Dates: Monday, July 8th - Friday, August 9th

Hours: 8:30am - 2:30pm, Monday- Friday

Mode: Fully in-person program.

Transportation: Door-to-door transportation is provided.

Grades: Current Kindergartners to current 3rd Graders (as of June 2024).

The program will serve K Go 1 students (current kindergarteners going into 1st grade in September 2024) up to 3 Go 4 students (current 3rd graders going into 4th grade in September 2024).

Please Note: We have currently reached out registration limit. Please fill out the application if you would like your student to be placed on the waitlist for Summer 2024.

Daily in-person attendance is important during the summer program. Enrolled students are expected to be present, on time, and prepared to learn and have fun! The fully in-person program runs Monday-Friday starting Monday, July 8th to Friday, August 9th from 8:30am-2:30pm.

Will the child enrolling miss any program days due to any planned vacations, religious holidays, trips, appointments, or any other reasons?

They will attend every day of the program.

I know that they will miss one or more days of the program.

Please list the dates the students will miss and the reasons why:

Student's Information

Student's Name

Student's Date of Birth

YYYY

Student's Gender

Male

Female

Other:

Student's Address

Student's Primary Language:

Language Spoken At Home

Student's Current School

Student's School ID Number

Student's T-Shirt Size

Youth XS

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Student's Race (check all that apply)

Asian

Native Hawaiian/ Other Pacific Islander

Black/African American

American Indian/Alaska Native

White/Caucasian

Other:

Student's Ethnicity

Latino/Hispanic

Not Latino/Hispanic

Does the student currently receive any of the following support services?

The information below helps us to best serve students in the program. We will make every effort to support the student using the information below, but the program is not positioned to provided the services.

Yes

IEP

504 Plan

AIS (Academic Intervention Support)

ELL (English Language Learner)

Counseling

Door-to-Door Transporation

Pick up and drop off times will be distributed before the program begins. Notify us immediately if you need to update your pick up or drop off location. Please note that address change requests may result in interrupted transportation.

Would you like a bus to pick up your child in the morning?

Yes

No, we don't need morning transportation. I will drop my child off at the program.

Morning Pick Up Address

Would you like a bus to bring your child home in the afternoon?

Yes

No, we don't need afternoon transportation. I will pick up my child at the program.

Afternoon Drop Off Address

Medical Information

Does the student have any medical conditions we should be aware of?

Yes

Please describe the medical condition and any other details we should be aware of:

Does the student take any medications?

Yes

Please be aware that the program does not have a registered nurse on staff and cannot administer medications.

Please list medications, dosages, and purposes:

Select any food allergies the student has:

Dairy Allergy

Peanut Allergy

Tree Nut Allergy

Shell fish Allergy

Fish Allergy

Milk Allergy/Intolerance

Egg Allergy

Vegetarian Diet

Vegan Diet

Other:

Does the student have any non-food allergies we should be aware of?

Yes

Please describe any non-food allergies:

Sunscreen Permission: In the event that a field trip involves outdoor activities and may require the application of zinc oxide or titanium dioxide sunscreen, does the program staff have permission to apply those products to prevent sunburn?

Yes, sunscreen may be applied.

Brockport Summer Learning Program 2024

Family Information

Parent/Guardian #1

Relationship to Student

Parent/Guardian 1

Mother

Father

Other:

Address

Parent/Guardian 1

Primary Phone Number

Parent/Guardian 1

Email Address

Parent/Guardian 1

Secondary Phone Number

Parent/Guardian 1

Is this person authorized to pick up the student?

Parent/Guardian 1

Yes

Is this person authorized to receive the student's assessment results?

Parent/Guardian 1

Yes

Would you like to provide information for a 2nd Parent/Guardian?

Yes

Parent/Guardian #2

Relationship to Student

Parent/Guardian 2

Mother

Father

Other:

Address

Parent/Guardian 2

Primary Phone Number

Parent/Guardian 2

Secondary Phone Number

Parent/Guardian 2

Email Address

Parent/Guardian 2

Is this person authorized to pick up the student?

Parent/Guardian 2

Yes

Is this person authorzied to receive the student's assessment results?

Parent/Guardian 2

Yes

First Emergency Contact (required)

Emergency Contact

Primary Phone Number

Email Address

Relationship to the Student

Is this person authorized to pick up the student?

Yes

Second Emergency Contact

Emergency Contact

Primary Phone Number

Relationship to Student

Is this person authorized to pick up the student?

Yes

Pick Up Authorization

Is anyone else authorized to pick the child up, other than those indicated above?

Yes

List other adults who are authorized to pick the child up. Please provide first and last name, phone number, and relationship to student.

Brockport Summer Learning Program 2024

Will your child's participation in the summer program allow you to do any of the following? (check all that apply or check "not applicable")

Work

Attend job training or school

Take care of family responsibilities

Not applicable

What are your child's strengths?

What are your child's areas of academic needs?

What do you hope your child will gain from the summer program?

Is there anything else we should know about the child in order to support them in the best way possible?

Brockport Summer Learning Program 2024

Media Release

I hereby release all rights to any photographs, digital recordings, videotapes, films or other images of me or my child(ren) and quotes and/or expressions said by me or my child(ren) during their participation in program. I am authorizing and providing full consent to The Research Foundation for SUNY to copyright and /or publish all photographs, digital recordings, videotapes and/or films, other images and quotes and/or expressions in which my or my child(ren) appears or are attributed to me or my child(ren). Further, I fully understand these photographs, digital recordings, videotapes and/or films, images, quotes or expressions may be used for public view and without remuneration to me, my family or any agents acting on my behalf. I further agree that The Research Foundation for SUNY may transfer, use or cause to be used, these digital recordings, photographs, videotapes, or films, images, quotes and expressions for any exhibitions, public displays, publications, commercials, art and advertising purposes, television programs, websites, social media and other forms of media without limitations or reservations. All images or quotes would be used in association with providing funders a view into the program or to further enhance program understanding, services, and funding.

Media Release:

I consent

I do not consent

Program Consents & Waivers

Participation in Programming & Field Trips: I give permission for my child, whose name is listed above, to participate in the Brockport Summer Learning program. My permission includes, but is no limited to: Transportation to and from program site; participation, including transportation, in all off-site activities, field trips and special events; academic and health assessment; and program learning and activities. I hereby release The Research Foundation for State University of New York (SUNY), State University of New York (SUNY); SUNY Brockport; and all employees, affiliates, officers and Boards of Directors of these three entities, of any liability, loss, damage, or injury incurred by me or my child during program transportation, off-site activities or program activities.

Emergency Medical Treatment: In the event of a medical emergency requiring immediate medical attention, I give permission for medical assistance to be given to the child listed above. Furthermore, if I cannot be reached and emergency care is needed, I give permission for program staff to make arrangements for the child listed above to be transported to the nearest hospital emergency room. The hospital has my authority to provide the child listed above all medical care they deem necessary, and I agree to be financially responsible for any and all care given.

Data sharing: I understand that The Research Foundation for SUNY, SUNY Brockport, and program partners, including my child’s school and the Rochester Summer Learning Collaborative will share and track information and data about my child following all federal and state laws regarding privacy and confidentiality. The information will be used only to help inform my child’s education.

Internet Usage: I give permission for my child to use the Internet at the program and hereby release the school from any associated liabilities.

Transportation plans: I agree that if my child’s 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.

The electronic signature below replaces a handwritten signature on paper.

I attest that I am the legal parent or guardian of the child named above. I affirm that the information I have submitted is true and accurate to the best of my knowledge.

Student's Full Name

Parent/Guardian Full Name

Parent/Guardian Signature

Use mouse or finger (not keyboard) to sign your name.

Date

2025