Bridge to Conwell-Egan Catholic Summer Camp

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Please fill out the following information to complete your registration for the Bridge to CEC Summer Program in Partnership with the 21st Century Community Learning Centers

Dates:
July 6th - July 30th
Monday - Thursday, 8:00 am - 12:00 noon

Work on summer reading and summer math assignments. BOOKS ARE PROVIDED!

Get a head start on your CEC journey by joining us this summer!

*PA Residents Only*

Email *

Student's Name *

Date of Birth *

YYYY

Gender *

Female

Male

Other:

Clear selection

I understand that I will have to provide transportation to and from the bridge program each day. You may check all that apply. *

I will drop off and pick up my child each day

PERMISSION: My child will be riding to and/or home with another parent

Other:

Required

Race/Ethnicity *

American Indian or Alaska Native

Black or African American

White

Hispanic or Latino

Multiracial

Asian

Other:

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Parent/Guardian Names & Phone Numbers *

Emergency Contact *

Family Doctor Name, Address, Phone *

Health Insurance

Does your child have any food allergies? *

Any medications your child takes? *

Is your child allergic to bee stings or other insects *

Yes

Unsure

Other:

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Any special health concerns? *

COVID-19 Protocols: I will do a routine medical check on my child everyday to ensure they currently have no symptoms of Covid-19. I WILL NOT send my child if they are experiencing any CDC listed symptoms and/or were a close contact to someone who has tested positive for Covid-19 *

Yes, I understand & Agree

Routine pictures/videos may be taken of your child while participating in a 21st CCLC program or club. These pictures/videos may be posted on bulletin boards for others to see or occasionally used for advertisement or press release. *

My child may have their picture taken

My child may not have their picture taken

Other:

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Permission for Treatment ..................... Should a medical emergency occur, we will make every effort to contact you about treatment for your son/daughter. In the event you cannot be reached, we ask that you give us permission to provide emergency medical treatment and follow-up care by a licensed physician. *

In the event I cannot be reached by telephone, I grant permission to the 21st CCLC and its personnel to provide emergency treatment.

I agree that I will not hold the 21st CCLC personnel liable for any acts/omission relating to the emergency medical treatment provided.

Other:

Student Code of Conduct.................................. The 21st CCLC works to provide a safe, fun, and educational environment for your child. We require all students to follow our Code of Conduct. All parents and children are required to read the Code of Conduct prior to attending the program. (Please check all to acknowledgment that you understand the rules and regulations) * *

My child will respect other people, including all the children and adults at the 21st CCLC program.

My child will use words to share their feelings that are respectful.

My child will listen and follow directions.

My child will use appropriate language.

My child will show respect to others by having a positive attitude when speaking to them.

My child will always use their “inside voice” when talking to others.

My child understands that no physical aggression (hitting, fighting, and/or shoving), verbal aggression (name calling, rumor spreading), or nonverbal aggression (intimidation, threatening gestures, excluding other students) will be tolerated at the 21 st CCLC program.

Other:

Required

YES! I would like to receive monthly newsletters

YES

Other:

Clear selection

Bucks County Technical High School Pennsylvania 21st Century Community Learning Centers

A copy of your responses will be emailed to the address you provided.

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