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STARTALK: Chinese Language Camp June 29 – July 17, 2015 8:30 – 3:00 PM Clarksville Middle School Please complete all information in this packet and return application and health form by mail to: Howard County Public Schools Office of World Languages 10910 Clarksville Pike Ellicott City, MD 21042 Attn: Leslie Grahn Registration is not complete until all three pages are returned with the registration fee of $50. Payment by check (made out to HCPSS) or credit card (see registration form) is accepted. If you have questions, don’t hesitate to contact us: Myriam Comito Director 410.313.2856 [email protected] Brenda Myrick Administrative Secretary 410.313.7485 [email protected] HOWARD COUNTY PUBLIC SCHOOL SYSTEM
2015 STARTALK SUMMER CAMP REGISTRATION Part 1: Biographical Information (PLEASE PRINT) Student Last Name: _______________________________________________________ First Name: ________________________________________________ Current Grade 2014-‐15 _______ Current School 2014-‐15: ___________________________________ School for Fall 2015: __________________________ Student Home Address Street: ___________________________________________________________________________________________________________________ City: ________________________________________________________________ State: ______________________________________ Zip: ____________________________ Parent/Guardian Last Name: _________________________________________________________ First Name: ____________________________________________ Parent/Guardian E-‐mail: ________________________________________________________________________________________________________________________ Home Phone: ( ___________) ___________________________________________ Wok/Cell Phone: ( ___________) __________________________________________ Student Ethnicity (check one): Hispanic  Yes  No Student Gender:  Male  Female Race/Ethnicity:  American/Indian/Alaskan Native  Asian Black/African American  Hispanic/Latino  Hawaiian or Pacific Islander  White Two or more races Part 2: Program Permissions/Notifications Parents or Guardians – Please read, initial where applicable, and sign below: I give permission for my son / daughter to participate in the program field trip. I will be notified of the specific date and destination for the field trip. I authorize the HCPSS STARTALK Chinese Language Camp staff to secure a copy of my child’s report card, test scores, and any other information that may be relevant to the success of my child. It is understood that this information will be handled confidentially. I agree to support my child’s achievement during this program by encouraging my child at home and by communicating regularly with the HCPSS STARTALK Chinese Language Camp staff. As a parent / guardian of , I grant permission for my child to be photographed and/or videotaped. I understand that photographs and video clips may be used for one of these purposes: • In a publication (i.e., local and/or national newspaper article) • On the school or program web site (your child’s name will not be included) • For use on local and/or national television. Discipline Policy The mission of the HCPSS STARTALK Chinese Language Camp is to provide an extended learning experience in a safe and nurturing environment. Students are expected to adhere to the Howard County Public School System Student Code of Conduct. Any student who refuses or is unable to interact cooperatively and respectfully with adults and other children will be dismissed from the HCPSS STARTALK Chinese Language Camp. Tuition fees will not be refunded. You will be notified if your child’s behavior puts him or her at risk of being dismissed from the program. Parents or Guardians: I have read and understand the HCPSS STARTALK Chinese Language Camp Disciplinary Policy. Parent / Guardian Signature ____________________________________________________________________________ Date __________________________ Part 3: Background Survey Student Last Name: _________________________________________________ First Name: _________________________________________
Is a student in HCPSS :  Yes  No (If no, indicate where) ___________________________________________________________________________________________________________
Has participated in a previous STARTALK Program  Yes  No (If yes, indicate where and when______________________________________________________________. Has studied Chinese previously:  Yes  No (If yes, indicate where and when) _____________________________________________________________________________________. T-‐shirt size: Small Medium Large X-‐Large Is there anything the teacher should know about your child? ____________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ Part 4: Payment Information Name on payment: Amount: $ Payment type:  Cash  Check*  Money order  Credit card Check#/Money Order #: Credit Card # Exp Date: / / Security Code #: * Please make your check payable to the Howard County Public School System.
The HCPSS Finance Office has contracted with the Envision Payment Solutions, Inc. for the electronic collection of check payments. If the check is returned
unpaid, Envision Payment Solutions, Inc. will assess a $35 fee allowed by Maryland state law and charged as an electronic fund transfer.
H o w a r d
C o u n t y
P u b l i c
S c h o o l
S y s t e m
Summer School Emergency Procedure/Health Information
Please print all information clearly. Provide telephone numbers including area codes.
Current school: ____________________________________________ Summer School Site: ________________________________________
Student’s name: __________________________________________________________________________________ Date of birth: __/__/____
Last name First name Middle initial
Street address: ____________________________________________________________________________________________________
City: _____________________________________________________________________________ Zip code: ____________________
Home phone: (_______)_________________ Work phone: (_______)_________________ Cell phone: (_______)_________________
Parent/Guardian Name: _____________________________________________ Student/Family Primary Language: __________________
Family Physician: _____________________________________________________________ phone: (_______)_________________
Summer School Emergency Notification
(List in order of notification. Parent/Guardian will be contacted first unless otherwise specified.)
Major emergencies will be taken to the nearest hospital.
1. __________________________________________________________________________________________________________
Name of person
Relationship
(area code) day time phone number
2. __________________________________________________________________________________________________________
Name of person
Relationship
(area code) day time phone number
3. __________________________________________________________________________________________________________
Name of person
Relationship
(area code) day time phone number
Other procedures desired: ______________________________________________________________________________________
___________________________________________________________________________________________________________
Summer School Health Information
(For Health Room use)
List any health conditions/handicapping conditions: _______________________________________________________________
List any allergies: _____________________________________________________________________________________________
Describe the usual symptoms/reactions or any deviation from the usual reaction: ___________________________________________
Does your child have any activity restrictions?
£Yes £No If yes, please explain. _________________________________________
____________________________________________________________________________________________________________
Will any medication be needed at school?
available in any school health room.
£Yes £No If yes, a written order from your Doctor is required. Medication forms are
• Immunization records, for children who have not attended school before, must be submitted and reviewed by the school nurse/ health assistant prior to the child attending summer school.
• The information you provide will be handled in a confidential manner. Information provided on this form will be reviewed and discussed with staff as necessary to maintain your child’s safety.
• Information provided on this form must be in compliance with Health Services policy and procedure.
Parent/Guardian Signature _______________________________________________________________ Date ____/____/________
For office use only: please make a copy of this form, send original to Health Services Office at ARL.
Send copy to the Front Office of student’s summer school.
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