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PROGRAM TYPE

2024 SUMMER CAMP INFORMATION

Mondays to Fridays, 8am to 4pm

June 13, 2024 to July 19, 2024

1739 Martin Luther King Jr. Pkwy, Wilson, NC 27893

Other Information

Food and Transportation will be provided.
Daily Math and Reading classes towards the next grade level.
Extracurricular activities such as band, vocals, dances, arts and crafts, cooking, STEM, character education, keyboarding and YouthTalks!
Educational Field Trips

Contact Us!

sipnayanllc@gmail.com

(252) 296-1702

I am applying for: *

STUDENT INFORMATION

Student's First Name *

Student's Last Name *

Gender *

Grade *

Age *

Birthday * +

Ethnicity

Hispanic/Latino

Not Hispanic/Latino

SCHOOL INFORMATION

School Name *

In SY 2023-2024, was your child promoted or retained? *

In SY 2023-2024, what was your child's lunch status? *

In SY 2023-2024, did your child have an Individualized Education Plan (IEP)? *

SY 2023-2024 Quarter 3 Academic Records

	Final Grade	EOG Score
Math	Final Grade	EOG Score
ELA/Reading	Final Grade	EOG Score

PARENT INFORMATION

Parent's First Name *

Parent's Last Name *

Street Address *

City *

State *

Zip *

Cell Phone Number *

Home Phone Number *

Work Phone Number *

Email Address *

Relationship *

MEDICAL INFORMATION

Does your child have any allergies?
Does your child take any prescribed medications?
Does your child have any special medical needs?

If applicable, please describe any health limitations relevant to your child. *

List any other things that we need to know about your child's medical needs/concern. *

Primary Physician *

Phone *

Physician Address *

Preferred Hospital *

Phone *

Hospital Address *

EMERGENCY CONTACT INFORMATION

1. First Name *

Last Name *

Cell Phone Number *

Relationship *

2. First Name *

Last Name *

Cell Phone Number *

Relationship *

TRANSPORTATION INFORMATION

Students who live in Wilson City will be picked up and dropped off by Sipnayan buses. Students who live in Wilson County outside of the city limits may be picked up and dropped off based on student enrollment. Students who live in paces with narrow streets or driveways may have to walk to the closest bus-accessible location.

Will your child need transportation from and/or to home? *

Please list authorized individuals to pick up your child from the center. *

	Name	Cellphone	Relationship
1)	Name	Cellphone	Relationship
2)	Name	Cellphone	Relationship
3)	Name	Cellphone	Relationship

Please list any individual/s (and their relationship to your child) NOT LEGALLY authorized to pick up your child from the center.

ACCEPTABLE USE POLICY FOR INTERNET ACCESS

Sipnayan Math Center provides access to the Internet for all students, faculty, and staff. Students must have written permission from at least one of their parents or guardians to access the Internet at the center. The use of the Internet is a privilege, not a right, and inappropriate use will result in the cancellation of those privileges and/or disciplinary action by school officials. A student’s activities while using the Internet in this program must be in support of education and research, and be constant with the educational objectives of the center. In addition, a student accessing the internet from this center is responsible for all online activities, which take place through the use of the internet. When using another organization’s networks or computing resources, students must comply with the rules appropriate for that network. The student agrees that the following actions (which are not all inclusive) constitute unacceptable use of the Internet, whether that use is initiated from the center or any other site:

● Using impolite, abusive, or otherwise objectionable language in either public or private

● Chat rooms without teacher supervision

● Placing unlawful information on the Internet

● Using the Internet illegally in ways that violate federal, state, or local laws or statues.

● Using the Internet at school for non-school related activities

● Sending messages that are likely to result in the loss of recipient’s work or system

● Sending a chain letter or pyramid schemes to lists or individuals, and other types of use which would cause congestion of the Internet or otherwise interfere with the work of others.

● Using the Internet for commercial purposes.

● Using the Internet for political lobbying.

● Changing any computer file that does not belong to the user.

● Sending or receiving copyrighted materials without permission.

● Submitting materials copied from the Internet as one’s own work.

● Using the Internet access for sending and receiving pornographic material, inappropriate test files, or files dangerous to the integrity of the network.

● Circumventing security measures on school or remote computers or networks.

● Attempting to gain access to another’s resources, programs, or data.

● Vandalizing, which is defined as any malicious attempt to harm or destroy data of another user on the Internet, including the uploading or creation of computer viruses.

● Falsifying one’s identity to others while using the Internet.

Student’s Agreement:

I have read the policy on Acceptable Use of the Internet at Sipnayan-21st CCLC Afterschool Program and I fully understand and agree to abide by the principles and guidelines it contains. In addition, I have to refrain from those actions listed, which are considered unacceptable to the proper use of Internet resources.

Student's Signature *

clear

Parent's Agreement:

As a parent or guardian of this student, I have read the Acceptable Use Policy for Internet Access. I understand that this access is for educational purposes. I also recognize that an employee of the school or school system may not be able to restrict access to all controversial materials on the Internet. I will not hold them responsible for materials my son or daughter acquires as a result of the use of the Internet on equipment provided on the school site. I hereby give my permission to Sipnayan Math Center to permit my child to access the Internet on equipment provided on the school site.

Parent's Signature *

clear

PERMISSIONS/AUTHORIZATIONS

1) Authorization for Leaving School Premises during Field Trips and Activities. I hereby give my child permission to leave the program site for all program activities supervised by Sipnayan staff including, but not limited to, local field trips.
2) Authorization for Emergency Medical Care. I hereby give permission to the staff of Sipnayan Math Center to call on our behalf for any doctor or emergency medical services that my child may need, in case I cannot be reached after conscientious effort to communicate with me or any of my child’s emergency contacts listed. I understand that I will be responsible for any expense of emergency transportation and medical treatment.
3) Movie Viewing Permission. It is possible that movies and/or TV shows may be watched during this program. My child may watch movies that are rated G.
4) Movie Viewing Permission. It is possible that movies and/or TV shows may be watched during this program. My child may watch movies that are rated PG.
5) Movie Viewing Permission. It is possible that movies and/or TV shows may be watched during this program. My child may watch movies that are rated PG-13.
6) Photographs and Media Release Permission. I hereby consent to the use of photographs/videotape of my child and my child’s guests taken during the course of the program for publicity, grant documentation for grant narratives, promotional and/or educational purposes (including publications, presentation or broadcast via newspaper, internet or other media sources). I do this with full knowledge and consent and waive all claims for compensation for use, or for damages.
7) Access to School-Based Data. I authorize the staff of Sipnayan Math Center to obtain my child’s academic and behavior records from my child’s regular school. I will assist in providing copies of these records provided to me by my child’s school, i.e. progress report, report card and test results. I understand that, in addition to meeting state and federal program requirements, this is necessary in designing an effective program for my child.

POLICIES/PROCEDURES

1) Discipline. Sipnayan Math Center uses a consistent, positive approach including redirection, diversion and separation, always promoting self-discipline. Parents will be notified if there is a consistent behavior problem. Parents may set up a meeting with the program coordinator/site coordinator to discuss individual needs and concerns.

a) Should inappropriate behavior occur, the concern will be discussed with the students, and a written warning will be given.

b) Should inappropriate behavior continues, a second warning will be given and the parents will be notified.

c) Should inappropriate behavior still continues, a third warning will be given, and the student will be suspended for 3 days.

d) Continued behavior problems may result in permanent dismissal.

2) Consequence of Fighting and Threats to Safety. It is our top priority to maintain the safety of our students and staff at all times. Students who are involved in fighting that results to physical injury, and other behavior that threatens the safety of other children and staff at the center or on the buses, will automatically be removed from the location and will have a 5-day automatic suspension. Parents or any authorized adult need to pick up the student within 30 minutes of notification.

3) Regular Attendance Policy. As in a regular school system, your child’s regular attendance to the program is a must to demonstrate academic progress or maintain academic success. Any student who have missed more than 30% of the monthly program days will receive attendance warning noted on the month's attendance update.

4) Child Pick-Up and Drop-Off. Students must sign in upon arrival at the program after an official school activity. Parents dropping off a student must sign in the student. Parents/authorized adult picking up a student must physically sign out the student. Staff will ask for picture ID of anyone they do not know. Individuals not listed as authorized to pick up will not be allowed to check out a child.

5) Attendance and Late Pick-Up. For the safety of the child, parents must notify staff if their child will be late or absent. If the child is registered to come and does not appear, we will call the parent and/or emergency contact numbers to locate the child.

6) Illness. It is in the best interest of your child and the other children if you keep your child at home when he or she is ill. Students with fever, diarrhea, or vomiting will not be admitted to the program. If a student becomes ill while at the program, the parent will be called immediately to pick up the child. Parents will be notified regarding contagious illnesses. Children will be readmitted when they are no longer contagious.

7) Medication. In accordance with state law, we will not dispense any medication to any child without advance written consent from the parent or guardian. Prescription medication may be given only to the child for whom it is prescribed. Over the counter medication must have the child’s name clearly printed on the container. The parent must complete a “Parent Permission to Administer Medication” form, and give the form and the medication directly to the director in charge. All medication must be in its original container. If these steps are not completed, medication will not be administered. Students who are required to take medication during program hours must have a written consent from the parent and the doctor administering the medication. Forms for this purpose are available from the director. All medication must be in its original container with an accurate pharmacy label intact.

8) Cellphone. Students are not allowed to use their celphones during the summer camp. Students observed to be using their cellphone will have the following consequences: 1st offense - cellphone will be confiscated and returned at the end of the day, 2nd offense - 1 day suspension, 3rd offense - exclusion from field trips. The cellphone policy for field trips will be included in the field trip permission slips.

9) Costs. The Sipnayan-21st CCLC Afterschool program is free of charge. This includes free transportation to students who live within Wilson County and free snacks during the program.

10) Parent Involvement. Parent involvement is one of the crucial involvement in the success of the afterschool program and the success of the child in the regular school setting. Parents are expected to provide contact information and have an open line of communication with the staff of Sipnayan Math Center. Parents may be contacted through the Remind101 app, email, phone or by person. The center requires the parents to attend and participate in all of the center’s activity in which parents are invited, i.e., parent workshops, culminating activities. Students whose parents do not participate will have the least priority for re-enrollment.

STATEMENT OF UNDERSTANDING

I have read, understand and agree to abide by the signed authorizations, permissions, agreements of policies and procedures of the Sipnayan-21st CCLC Afterschool Program listed below. I understand the mission, vision and expectations of the Sipnayan-21st CCLC Afterschool Program and would like my child to be enrolled in the program.

★ Authorization for Leaving School Premises during Field Trips and Activities

★ Authorization for Emergency Medical Care

★ Movie Viewing Permission

★ Photographs and Media Release Permission

★ Access to School-Based Data

★ Guidance

★ Discipline

★ Consequence of Fighting and Threat to Safety

★ Regular Attendance Policy

★ Child Pick-Up and Drop-Off

★ Attendance and Late Pick-Up

★ Illness

★ Medication

★ Cellphone Policy

★ Costs

★ Parent Involvement

Student's Signature *

clear

Parent's Signature *

clear

Attachments

Attach student's 3rd Quarter Report Card.

Attach student's IEP/504 Plan, if any.

Save & Return

PROGRAM TYPE

STUDENT INFORMATION

SCHOOL INFORMATION

PARENT INFORMATION

MEDICAL INFORMATION

EMERGENCY CONTACT INFORMATION

TRANSPORTATION INFORMATION

ACCEPTABLE USE POLICY FOR INTERNET ACCESS

PERMISSIONS/AUTHORIZATIONS

POLICIES/PROCEDURES

STATEMENT OF UNDERSTANDING

Attachments

For Official Use Only