Information for Summer Art Program 2017
Child’s name: ___________________________________________________________
Home Phone # ____________________
DOB: ______ Grade:_____ School: __________________
School User ID No. _____________
Parent /Guardian’s email: __________________________________________________ Parent /Guardian Cell Phone # __________________ Work # _______________
Parent/Guardian’s name: __________________________________________________ Parent /Guardian’s email: _________________________________________________ Parent /Guardian Cell Phone # _____________________ Work #__________________
Person Picking Up Your Child Each Day: ______________________________________
Name: ______________________________Telephone # _________________________
Medical Info: Does your child have allergies, an illness or other conditions the nurse on duty should be made aware of? If so, please explain.
Any student requiring medication or a medical procedure during the Summer Program needs to have a doctor’s order on file with the nurse on duty.
___My child has my permission to be photographed for the newspaper or Burlington Public Schools’ use (e.g., Burlington’s school website and/or brochures).
___My child does not have my permission to be photographed for the newspaper or Burlington Public Schools’.
___My child has my permission to access the internet with teacher supervision.
___My child does not have my permission to access the internet with teacher supervision.
Parent/Guardian’s signature:______________________________ Date: ____________