paint_palette__1_.jpg           Information for Summer Art Program 2017

Child’s name:   ___________________________________________________________

Address: ________________________________________________________________

Home Phone #  ____________________

DOB:  ______                Grade:_____                                   School: __________________

School User ID No. _____________                

Parent/Guardian’s name:___________________________________________________

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:   ______________________________________                

Emergency Contact:

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.

Photographs:

___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’.                  

Computer Use:

___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:        ____________