2008 Summer Camp Application
Rochester Young Scholars Academy at Geneseo (RYSAG)
This application needs to be filled out completely and mailed by Saturday, May 31, 2008. Space for the program is limited; students with late applications may be turned down. In addition, in order to be accepted, the student’s Health Evaluation Form must be cleared at Pre-Registration on June 14, 2008. Please mail back forms to: Susan Norman, SUNY Geneseo, South Hall 207, Geneseo, NY 14454.
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Student Information:
Name:______________________________________________________________
Street Address:_______________________________________________________
Home Phone ( ) ________ -_______________
Date of Birth: _____/_____/__________
E-mail address (If applicable):____________________________________________
____________________________________________________________________________________________
Parent/Guardian contact information:
Name:______________________________________________________________
Address:____________________________________________________________
Phone ( ) ________ -_______________
Relationship to Student:_________________________
Name:______________________________________________________________
Address:____________________________________________________________
Phone ( ) ________ -_______________
Relationship to Student:_________________________
____________________________________________________________________________________________
Emergency Contact information:
Name:______________________________________________________________
Address:____________________________________________________________
Phone ( ) ________ -_______________
Relationship to Student:_________________________
Name:______________________________________________________________
Address:____________________________________________________________
Phone ( ) ________ -_______________
Relationship to Student:_________________________
____________________________________________________________________________________________
Summer Camp Recommendation Form
All students must have at least one adult that will recommend them to the Academy and summer camp. Please ask one of the following individuals to complete a recommendation for you: Teacher, Counselor, Clergy, etc.
Name of person that is recommending the student for the summer camp:
Name:______________________________________________________________
Address:____________________________________________________________
Phone ( ) ________ -_______________
I, ___________________________________, recommend ___________________________________ to participate in the Rochester Young Scholars Academy at Geneseo (RYSAG) during the summer of 2008.
State your reasons for recommending the student, including your knowledge of his/her academic record and character:
The above student goes to school at: __________________________________________________________________
Approximate GPA:______
Parent/Guardian Agreement
with the Rochester Young Scholar Academy at Geneseo
The Rochester Young Scholars Academy at Geneseo will make every effort to provide for my child’s well being during the hours of the program and will make every effort to immediately contact the parent should any type of emergency arise.
The RYSAG program for my child begins when the child has reached the program and checked in with a RYSAG staff person. My child is responsible for walking from the Bus or personal car to the RYSAG program (at appointed site).
I will be available during the camp time of July 14-25, 2008 to pick up a sick child or for any other emergency that may arise. If I am not home, I will leave instruction for an appointed guardian to take my place. This guardian is also named as an emergency contact in this application.
I hereby give permission to record the image and/or voice of my child for newsletters, special projects, brochures, web sites or newspaper releases.
I hereby give permission for the RYSAG program to use school records (report cards) to help my child with learning strategies.
It is my responsibility to arrange for my child to be picked up or take a bus at the close of the camp. Staff should not provide transportation for your child.
If I change my address or phone, I will notify the RYSAG staff as soon as possible so that I will continue to stay in contact with the Academy.
I have provided the staff with pertinent, complete and correct information which may assist the RYSAG Program in caring for my child, including, but not limited to allergies, previous or existing illness or conditions, sunburn sensitivity, diet requirements, long term medication, disabilities or limiting conditions, emotional development or behavioral difficulties.
My signature acknowledges my understanding of the above and that all information I provide is accurate and complete.
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Parent/Guardian Name (please print)
________________________________________ Date: _____/_____/_________
Parent/Guardian Signature