Eaton Academy
Education Solutions for Every Mind, Every Age
Summer L*E*A*P Enrollment Application and Agreement
Section One (To Be Completed For All Participants)
Email Address: ____________________________________
Participant’s Name ______________________________________________________ Date ________________
Last
First
Middle
Mailing Address _____________________________________________________________________________
Home Phone________________________ County of Residence ______________ Age_____ DOB ____________
Father’s Name__________________________ Phone (H)_____________(W)_____________(Cell)___________
Home Address (if different) _____________________________________________________________________
Street
City
State
Zip
Mother’s Name__________________________Phone (H)_____________(W)_____________(Cell)___________
Home Address (if different) ____________________________________________________________________
Street
City
State
Zip
Section Two (To Be Completed For Non-Eaton Academy Participants)
Answer YES or NO about the participant (Use additional paper if necessary)
1. Any physical, visual or auditory difficulties?__________If yes, please explain _______________________
2. Is the participant in good health?__________If no, please explain _______________________________
3. Does the participant take any medications?_______ If yes, please explain:_________________________
4. Does the participant have allergies (including food allergies)? _____ If yes, please list: ________________
_______________________________________________________________________________
Name of participant’s physician____________________________ Phone ______________________
5. Does the participant wear eye glasses or contact lenses?_______________
6. Has the participant ever been involved with law enforcement? Yes___ No___ If YES, please explain below:
________________________________________________________________________________
7. Has the participant ever been subject to major disciplinary action (suspension or dismissal) in any school?
Yes____ No___ If YES, please give dates and details:_______________________________________
________________________________________________________________________________
8. Will the participant drive himself/herself to and from LEAP? Yes____ No____
If YES, may the participant transport others in the LEAP? Yes____ No____
If NO, who will be driving the participant to and from LEAP? _______________________________
9. Do you wish Eaton to obtain identification from any individual(s) who arrive to pick up the participant?
Yes____ No____ If YES, please list all individuals who have permission to pick up the participant:
________________________________________________________________________________
10. Does the participant consent to being photographed and filmed for publicity purposes? Yes____ No___
Section Three (To Be Completed For All Participants)
Please indicate which session(s) the participant will attend:
____ 1st Session (June 8 through 26)
____ 2nd Session (July 6 through 24)
The admissions policy of Eaton Academy is non-discriminatory with regard to race, creed, sex, or ethnic or national origin.
(Please turn the page to continue)
Section Four TERMS OF SUMMER L*E*A*P PROGRAM
Dates: First Session: June 8 – June 26 and Second Session: July 6 – July 24 Hours: 9:00 a.m. – 1:00 p.m.
Requirements: Participants must be rising juniors, rising seniors, or high school graduates.
Tuition: $1,800.00 per session due by June 1, 2015 (for First Session), and by July 1, 2015 (for Second Session)
A $500.00 Deposit Is Required To Ensure Placement
Terms and Conditions
1.
Full payment must be received according to the above schedule. Tuition is completely non-refundable, unless a session is
cancelled by Eaton Academy (herein: “the Company”). In which case, tuition will be refunded in full.
2.
The Parent and the Participant acknowledge reading and will abide by Eaton Academy’s regulations and policies as stated
in the Parent/Student Handbook (available online at www.EatonAcademy.org). Any violation or breach thereof by the
Participant may result in disciplinary action, including suspension or dismissal from the Program with no refund of tuition
and fees. These regulations are incorporated into this agreement. The Company reserves the right, from time to time to
change, amend, add to, or delete portions of the Regulations as necessary.
3.
The Parent and the Participant understand, acknowledege, and agree that the Participant may be riding with other program
participants and using public transportation (MARTA) during the Summer L*E*A*P Program.
4.
The Parent and the Participant understand, acknowledege, and agree that the Participant may be transported by L*E*A*P
Program staff members in a voluntary transportation arrangement.
5.
The Parent and the Participant understand, acknowledege, and agree that participants will prepare lunch on a daily basis. A
menu for which will be provided in advance. Peanut butter and jelly will be available each day. If the Participant has
specific dietary restrictions or allergies, they must be listed on this application/agreement, and the participant will need to
bring his/her own food.
6.
Participants must follow the Dress Code as listed in the Handbook – Monday through Thursday: Appropriate shorts and a
collared shirt are required; no T-shirts, tank tops, or sandals.
7.
The Company maintains a zero tolerance for drugs, alcohol, tobacco, and weapons. This zero tolerance includes the
possession and/or use of any of the above items as well as the possession and/or use of any paraphernalia associated with
any of the above items. Further, inappropriate conversation about and/or an attitude that promotes the use of any of the
above items is subject to the zero tolerance policy. The Parent and the Participant understand, acknowledege, and agree that
as part of this zero tolerance policy the Participant’s enrollment can be terminated at the Company’s discretion for whatever
is, in the Company’s opinion alone, a violation of this zero tolerance policy. Should the Participant’s enrollment be terminated, all tuition and fees due the Company must be paid by the Parent. The Company also maintains a zero tolerance policy
toward the inappropriate use of technology (see Parent/Student Handbook page 3).
8.
Participants will be performing various culinary tasks such as (but not limited to) cutting, chopping, slicing, sautéing,
baking, and broiling. The Parent and the Participant understand, acknowledege, and agree that these tasks can be hazardous and that they assume full risk and liability associated with such tasks.
Please read this statement carefully and sign below:
We have completed this application to the best of our ability, and we hereby certify that all statements made are true and accurate to
the best of our knowledge. Additionally, we hereby acknowledge reading, understanding, and agreeing to the terms, conditions,
permissions, and expectations contained in this application. We hereby covenant and agree that Eaton Academy, Inc., its owners,
officers, instructors, agents, and staff (the “Released Parties”) shall not be liable for any damages including, without limitation,
compensatory damages, punitive and exemplary damages, and pain and suffering and damage to property which may in any way
result from or arise out of the transportation or culinary activities. We hereby fully and forever release and discharge and covenant
not to sue the Released Parties for any and all claims, demands, damages, rights of action or causes of action, present or future,
whether the same be known or unknown, anticipated or un anticipated, resulting from or arising out of my transportation and
culinary activities while participating in the L*E*A*P summer program.
________________________________________
______________________________________
Parent/Guardian Name
Student Name
________________________________________
Signature of Parent/Guardian
______________________________________
Signature of Student
______________________
______________________
Date
Date
Eaton Academy is accredited by the Southern Association of Colleges and Schools Council on Accreditation and School
Improvement (SACS/CASI, a division of AdvancED) and by the Georgia Accrediting Commission (GAC).