SUMMER 2017 REGISTRATION PACKET

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1 SUMMER 2017 REGISTRATION PACKET

2 PENN HILLS SCHOOL DISTRICT FREE SUMMER PROGRAM MORE MAGIC IN THE MIDDLE with (GPS) Gateway to Providing STEAM Penn Hills School District MORE Magic in the Middle GPS will offer students entering Grades 5 through 8 in the school year, a meaningful summer learning experience held in a safe and supportive environment with caring adults. The program is limited to the first 100 registrations. Registration deadline is Friday, June 16, Please have your child return forms to their main office. The Program will: Provide transportation for students at their regular bus stops Start on Monday, June 26, 2017 through Friday, August 4, 2017 Operate Monday through Friday (9:00AM 1:00PM) at the Penn Hills High School Provide a breakfast and lunch to students Provide tutor support for students from caring adult teachers and paraprofessionals who will help coach and motivate using non traditional methods and fun activities! Provide a host of other community organizations which include Science, Technology, Engineering, Arts and Math (STEAM); physical education program (SPARKpe); Tabitha s Place; and Youth Project. Penn Hills School District partners with Communities In Schools of Pittsburgh Allegheny County to provide a 21 st Century Community Learning Center funded by the Pennsylvania Department of Education. For Further Information please contact: Ms. Jean Olivis, jolivi@phsd.k12.pa.us (412) Ext or Ms. Stefanie Raspotnik, sraspo@phsd.k12.pa.us (412) Ext. 1264

3 MORE MAGIC IN THE MIDDLE with (GPS) Gateway to Providing STEAM Penn Hills School District 21 st Century Community Learning Center June 26, 2017 August 4, 2017 STUDENT NAME: GRADE: STUDENT ADDRESS: Zip Code: STUDENT S HOMEROOM TEACHER: PRIMARY PARENT/GUARDIAN: Home Phone Number ( ) Cell Phone Number ( ) Address: In case you can not be reached, please list name and phone of at least 2 other people who could be contacted in case of emergency: Name Phone ( ) Name Phone ( ) Please list your bus stop: If your student is to be picked up at the high school, who will pick him/her up? Please note: Your child will only be released to the people whose names are provided on this form. Name Relationship to Student Name Relationship to Student IMPORTANT NOTICE: The Penn Hills School District Program will follow all rules, regulations, and codes of conduct in place by the District in partnership with the PA Department of Education and Communities In Schools. Registration for the program is on a first come first served basis and there will be 100 slots available. There is also a 90% mandatory attendance policy for the program. All forms must be completed in the application packet. Parent/Guardian s Signature 1

4 PENN HILLS SCHOOL DISTRICT Summer 2017 More Magic in the Middle with GPS Program Emergency Care Card in Case of Sudden Illness or Injury Present Grade Teacher Pupil's Name Please Print All Items Birth Last Name First Middle Mo.-Day-Yr. Address Zip Home Phone Father's Place of Employment Mother's Place of Employment Work Phone *Cell Phone Work Phone *Cell Phone *Please make sure all contact numbers are updated if changes are made. NOTE: AS THE CARE AND TREATMENT OF ANY CHILD IS PRIMARILY A PARENTAL RESPONSIBILITY, EVERY EFFORT WILL BE MADE TO CONTACT THE PARENT FIRST. In case of accident or illness in school and parents cannot be located, please contact: Neighbor's Name Neighbor's Address Neighbor's Name Neighbor's Address In case of an emergency and it is necessary to call a physician, please contact: Phone Phone Family Physician Phone If unable to contact parent or doctor, permission is granted to arrange for emergency hospital treatment if required in keeping with police emergency regulations. Unusual health conditions (diabetes, heart condition, allergies, and etc.) PLEASE WRITE NONE, IF HAVE NO UNUSUAL HEALTH CONDITIONS. : Signature of Parent or Guardian: Penn Hills Police Department In the event of emergency, ambulances are to be dispatched to the nearest hospitals which are: Forbes Regional Health Center, Monroeville St. Margaret's Hospital, Pittsburgh The only exception to this general rule will be cases involving children where necessary treatment can be obtained only at Children s Hospital. 2

5 PENN HILLS SCHOOL DISTRICT 21 st Century Community Learning Center funded by PDE Summer 2017 at Penn Hills Senior High School MORE Magic in the Middle with GPS (Gateway to Providing Steam) (Must be completed with signatures!) Release of Grades, Behavior, and Attendance Reports As a requirement of the grant, I understand it is necessary for Penn Hills School District, along with Communities in Schools to collect and examine academic, attendance and behavior records for the students while providing service under the Pennsylvania Department of Education funding for 21 st Century Community Learning Center Programs. This authorization will remain in effect for the duration of your student s participation in the program unless revoked in writing by the Parent/Guardian. STUDENT S NAME: Parent/Guardian Signature Penn Hills School District 21 st Century Community Learning Center More Magic in the Middle Publicity Release Form I hereby give Penn Hills School District and Communities In Schools the right and permission to use my name, image, words, and/or works in its educational and promotional materials, as well as it publicity efforts. I understand that this could include district publications/productions, print ads, direct mail pieces, electronic media (i.e., video, CD-ROM, Internet WWW), outside publications, or other forms of promotion. I release the District, its employees, agents, and designees from liability for any violation of any personal or proprietary right I may have in connection with such use. I also understand that I will not receive compensation for this use, and this use is for the indefinite period unless otherwise specified. Please sign below to give permission for your child to speak with a representative of the media. Note that this will authorize Penn Hills School District and Communities In Schools to provide the media representative with contact information for your child. This authorization will remain in effect unless revoked in writing by the student s parent/guardian. Parent/Guardian Signature 3

6 MORE MAGIC IN THE MIDDLE with (GPS) Gateway to Providing STEAM Summer Parent Involvement Form Penn Hills School District 21 st Century Community Learning Center June 26, 2017 August 4, 2017 I, will participate in the Parent Involvement activities as a requirement of the PA Department of Education s 21 st Century Community Learning Center. This may include attending student presentations and parent workshop. Student Name Present Grade Parent/Guardian s Signature 4

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