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PARK ACADEMY
THE DISCOVERY OF INTELLECTUAL GIFTEDNESS
2015 Summer School Application
Grades 3-12
Submission of this application and a $100.00 deposit for each class (applied to tuition) are
required by Friday, May 22nd to attend our summer school program. The remaining balance of
tuition will be due June 15, 2015. There will be a supervised lunch from 12:00pm - 12:30pm if you
are staying for an afternoon class. Bring your own food and beverages.
There are two pages of summer fun for you to choose from. Please check the box for the classes
you are registering for. (See both sides.)
EXPLORE YOUR BRAIN POWER - Enrichment & Creativity
June 29-July 24 (M-F)
8:00am– 12:00pm
Four component classes include:
$1000.00
• Reading & Writing for Excellence - Strategies to further enhance reading and writing skills.
• Collaborative Arts and Creative Expression - Creative activities that improve communication
• Integrated Math & Art - Project based, hands-on learning
• Social Skill Building - Our Brains, Using Our Senses for Awareness, Our Attitudes & Being Mindful
This highly engaging and interactive four-week program of study is designed to use multi-sensory
instructional methodologies to help students expand their literacy, math skills and social skills. Through
intellectually stimulating and fun activities, students will be immersed in creative and innovative learning
expeditions such as math experiments, collaborative writing projects, and application based experiences
in the community. Students will be divided into cohorts and take each class for 50 minutes. Don’t forget
to bring a snack for break/recess.
AMPS CAMPS - Attention, Memory and Processing Speed
June 29-July 24 (M-F)
12:30pm – 3:30pm
$750.00
AMPS focuses on developing underlying skills which make learning easier. These skills provide
mental tools that help students think and learn, and include; attention, memory, auditory and
visual processing (the ability to accurately think about, and make sense of, what we see and
hear), organization, reasoning and processing. This cognitive training program is offered by Dr.
Judy Belk from the Center for Communication & Learning Skills.
(include with two-page application)
Class
EXPLORE YOUR BRAIN POWER
AMPS CAMPS
SUMMER SOCCER FUN
NOTHIN’-BUT-NET BASKETBALL CAMP
EXPRESSIONS IN SANDPLAY
Deposit
Cost
($100 per Class)
$ 1,000
$ 750
$ 750
$ 750
$ 300
Total
(Due 5/25/15)
Remaining
Balance
(Cost - Deposit)
(Due 6/15/15)
Amount Enclosed:
Payment Method:
Cash
Check (made payable to Park Academy)
Credit Card:
Visa
MasterCard
Name on Card
Exp. Date
American Express
Card Number
/
CID
Billing Zip Code
Discover
Applicant Information
Legal Last Name
Gender
Legal First Name
Date of birth (month/day/year)
Preferred Name
Current Grade
Place of birth (city/state/country)
SSN
Address
City
State
Phone
Parent/Guardian primary email address
Zip
School Information
Current School
Telephone
Grade(s) attended
Address
City
State
Parent/Guardian (A) Information
Parent’s/Guardian’s Name
Relationship to applicant
Spouse/Partner, if not child’s parent/guardian
Address (if different from applicant)
City, State and Zip
Cell Phone
Work Phone
Home Phone
Email
Occupation
Employer/Firm Name
Parent/Guardian (B) Information
Parent’s/Guardian’s Name
Relationship to applicant
Spouse/Partner, if not child’s parent/guardian
Zip
Address (if different from applicant)
Cell Phone
City, State and Zip
Work Phone
Occupation
Home Phone
Email
Employer/Firm Name
Emergency Contacts
Who should be notified in case of emergency other then parent/guardian
First Contact Name (other than parent)
Home Phone
Work Phone
Second Contact Name (other than parent)
Home Phone
Relationship to applicant
Cell Phone
Relationship to applicant
Work Phone
Cell Phone
Physicians Name
Phone
Dentist Name
Phone
Hospital
Please indicate any medical conditions the school should be aware of:
Allergies/Specify
Bee Sting
Heart Condition
Vision Problems
Asthma
Migraines
Hearing Problems
Bleeding Disorder
Diabetes
Seizures
Other:
Please indicate any medications the student is currently taking:
In an emergency, if the Parent/Guardian, designated Physician/Dentist cannot be reached, I authorize Park
Academy to transport and/or obtain medical services from any doctor for my child.
Parent/Guardian Signature
Date