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PROGRAM TYPE

2021 SUMMER CAMP APPLICATION
 
Dates
9am to 4pm
June 14, 2021 to July 16, 2021
July 5, 2021 - No Summer Camp (Holiday)
 
Notes
1) Food and transportation will be provided.
2) Follow CDC guidelines - required masks, social distancing, washing/santizing hands.
3) Bridge academic gaps in Math and Reading due to COVID19.
4) Offer extracurricular activities such as band, vocals, dance, arts and crafts, cooking, PE, STEM, character education, keyboarding and YouthTalks!.  
5) Field trips, as permitted by CDC guidelines.
 
Location
Grades 3 to 5: 3475 B-D Airport Blvd, Wilson, NC 27896
Grades 5 to 8: 2302 Cedar Run Pl, Wilson, NC 27896
Contact Us!
Email: sipnayanllc@gmail.com
Call: (252) 296-1702

STUDENT INFORMATION

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Ethnicity
Race
 
 Yes/NoCellphone Number
Do you permit Sipnayan to include your child's cellphone number in our communication system?

SCHOOL INFORMATION

SY 2020-2021 Quarter 3 Academic Records
 Final GradeEOG Score
Math
ELA/Reading
Science
Social Studies

PARENT INFORMATION

MEDICAL INFORMATION

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EMERGENCY CONTACT INFORMATION

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 limites 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.
Please list authorized individuals to pick up your child from the center. *
 NameCellphoneRelationship
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3)
Please list any individual/s NOT LEGALLY authorized to pick up your child from the center.
 NameCellphoneRelationship
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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 *
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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

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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. ​As a 21st Century Community Learning Center, Sipnayan allows students to bring their cellphone to the center. On the other hand, students may only use their phone during snack time and whenever needed for classroom instruction. Students with cellphones may not take pictures or videos of other students in the program. Students are not allowed to share their cell phone or its content to another student of the program. A student's cellphone may be confiscated and returned at the end of the day. Repeated violation may result in suspension. 
 
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 *
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Parent's Signature *
clear

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