Rialto Aerospace Academy Application 2016
Student's Name *
Address *
City *
State *
Zip *
Phone
Email address
Date of Birth *
Student's School *
Current Grade level
Current GPA
Male or Female? *
Parents/Guardian Names *
Address *
City *
State *
Zip *
Home Phone *
Work Phone
Cell Phone *
Email Address *
Emergency Contact (other than parent/guardian) Name *
Relationship to Student *
Home Phone *
Cell Phone *
Work Phone
Name of Persons authorized to pick up student *
Relationship to student *
Home Phone
Cell Phone *
Work Phone
Name of Persons authorized to pick up student *
Relationship to student *
Home Phone
Cell Phone *
Work Phone
Student's Medical Information *
Are there any general health concerns/allergies that we need to be aware of? YES or NO
If YES, please explain
Please describe any physical limitations *
NONE if no limitations
Please list/describe any special dietary needs/requirements *
NONE if no needs or requirements
Emergency Medical Contact Information: Primary Physician's Name
Phone
Insurance Provider
Special Considerations *
Please list any other special considerations that we should be aware of
Essay *
Please briefly tell us why you would like to attend the Aerospace Academy
Consent Forms and Release Statements *
Please print Student's Name
Date *
MEDIA RELEASE: I hereby grant permission to Shades of Blue to use photographs, videos or program comments of my son/daughter to be used in connection with the making, promotion or public relations for the educational programs of Shades of Blue aerospace camps. *
YES or NO
Parent/Guardian Signature and Date *
MILITARY INSTALLATION VISIT and MILITARY RECRUITER PRESENTATION RELEASE: I understand and acknowledge that during the Shades of Blue aerospace academy that my son/daughter, may enter and tour a military installation and/or fly on a military aircraft as part of the camp’s itinerary. Additionally, recruiters from the U.S. Military may visit and speak on behalf of their respective organizations. I hereby grant permission to Shades of Blue and/or its agents to allow my Son/ Daughter to visit such installations, listen to their presentations, and to speak to their representatives. *
YES or NO
Parent/Guardian Signature *
Date *
PARENT/GUARDIAN ACADEMY AGREEMENT - Parents will ensure that students arrive at the aerospace academy on time every day. Parents will ensure that students are picked up on time at the end of every day. Parents will ensure that students bring all required materials to the academy every day. PARENTS WILL SIGN STUDENTS IN/OUT OF THE ACADEMY EVERY DAY *
Parent/Guardian Signature
Date *
SHADES OF BLUE MEMBERSHIP CONSENT Shades of Blue would like to enroll the graduates of our aerospace camp in Shades of Blue. The purpose is to track the progress of our graduates toward their career goals. The membership is free. All information will be kept confidential. ___________ I will go to the web site www.ourshadesofblue.org and enroll my child as a member of Shades of Blue. *
YES or NO
Parent/Guardian Signature *
Date *
STUDENT AGREEMENT and STUDENT GUIDELINES - Drugs, alcohol, tobacco products, weapons, beepers, laser pointers, electronic devices/games, Ipods, mp3 players, radios, are not permitted and will be confiscated. Cell phones must be turned off except during breaks. Students must report on time each day or risk missing the field trips. Students must participate in all daily activities. Students must wear appropriate shorts, slacks, jeans or skirts, tennis or sport type shoes and name tag everyday. Pants will be worn at the waist with a belt – no sagging! On field trips, we’ll be in airport hangars, climbing in and out of airplanes and other types of activities, so, for your safety, no sandals or open toe shoes, no short shorts, short skirts, baggy oversized style jeans, and no facial jewelry such as nose or eyebrow rings. Parents must sign Students IN and OUT of the academy daily. Students are not allowed to leave early without prior coordination between parents and camp directors. Students must use the sponsor-provided transportation for field trips. Students must bring a government issued photo ID. SAFETY TIPS - This is a fast-paced week - pay attention to what is going on around you. Watch out for sharp objects around aircraft/equipment -- especially at eye level. Take care entering and exiting: 1. bus 2. aircraft 3. other facilities. Your Camp Directors and designated Flight Instructors will brief you on all special emphasis Safety items for the day. Pay close attention to these briefings and abide by all of the rules to ensure maximum safety. Reckless behavior will not be tolerated. Our Camp Coordinators have designed the week of activities to ensure your safety throughout the aerospace camp, however, you are ultimately responsible for your own safety and assuring you have a safe week. I have read and understand all of the information listed above, and I agree to follow all student guidelines and safety tips while attending the Aerospace Camp. *
Please read the information listed above and sign below - Student Signature
Printed Name *
Date *
Thank you for selecting the Shades of Blue aerospace academy. We will ensure that all our students have a rich and rewarding experience during the camp. We encourage you to help us make this experience a valuable experience by ensuring that your child meets all the requirements and standards set forth by our Camp Director and his/her staff. We want nothing more than to provide a safe environment for all of the students and make this an experience that they will not forget. If you have any questions, please contact the Shades of Blue Aerospace Camp Director. Please submit all completed applications to the Camp Director via this link or print and mail to Shades of Blue Academy Director, 13990 Iroquois Road, Apple Valley, CA 92307, or fax to 760-247-0935, or email to f4tony@aol.com. All applications must be postmarked or dated by February 12, 2016. Remember to attach the Student’s Essay (“Why I want to attend the Shades of Blue Aerospace Academy”), and a copy of his/her latest Report Card. Make sure your student has a government issued photo ID and transportation to and from the camp location (Frisbie Middle School, 1442 N. Eucalyptus Avenue, Rialto, CA 92376) each day. If selected to attend the Aerospace Academy, you will receive notification NO LATER than February 15, 2016. If you have any questions, please contact Academy Director, Tony Marshall at 760-247-0456, 760-963-1177 or f4tony@aol.com
Date Submitted
Note: Meeting dates for this academy will be February 20, 27, March 5, 12, 19 (8 am to 12:15 pm each Saturday)
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