STUDENT APPLICATION
I.M.P.A.C.T. 2017 Summer Camp
STUDENT NAME *
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AGE *
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Nickname
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DATE OF BIRTH *
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SEX *
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HOME PHONE NUMBER *
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HOME ADDRESS *
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ZIP CODE *
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E-MAIL ADDRESS *
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SCHOOL NAME *
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DOES YOUR CHILD RECEIVE FREE LUNCH AT SCHOOL *
LIST ANY HEALTH ISSUES YOUR CHILD MIGHT HAVE
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HOW DID YOU HEAR ABOUT CHANGING LIFE EDUCATION *
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LIST ANY FOOD ALLERGIES YOUR CHILD HAS
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ARE YOU A STUDENT AT LEO HIGH SCHOOL *
T-SHIRT SIZE *
PARENT OR GUARDIAN INFORMATION
FATHER /MOTHER /GUARDIAN NAME *
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ADDRESS *
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CITY *
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STATE *
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ZIP *
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PHONE (H) *
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(C) PHONE
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OTHER PHONE NUMBER *
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Untitled Section
I HEREBY GIVE PERMISSION FOR MY SON/DAUGHTER_______________________ TO PARTICIPATE IN CHANGING LIFE EDUCATION INITIATIVE, INC., SUMMER PROGRAM. I WILL NOT HOLD LIABLE THE FACILITY(LEO High School) OR ORGANIZATION (CHANGING LIFE EDUCATION) WHERE MY SON/DAUGHTER PARTICIPATES IN PROGRAMMING, INCLUDING AND NOT LIMITING PROGRAMING ON ITS PREMISES OR OFF PREMISES SUCH AS SWIMMING,OR FIELDTRIP ACTIVITIES.
I GIVE MY SON /DAUGHTER’S PERMISSION TO BE USED IN ANY PHOTOS, IMAGES, VIDEO, ETC., THAT WOULD BE INCLUDED IN ANY CHANGING LIFE MEDIA & PROMOTIONS, WEBSITE PAGE AND PROMOTIONAL BROCHURES; USED HOWEVER SEEN FIT BY THE EXECUTIVE DIRECTOR.
CHILD NAME *
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PARENT SIGNATURE *
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As a parent/legal guardian of ______________________Child Name) I have reviewed the information about the Changing Life Education Initiative, INC Summer Education and mentoring Program, and grant permission for my child/ward to be involved in the overall activities.

Location: Leo High School, Chicago IL 60620
Start Time, Date: First segment June 12, 2017- July 7, 2017
Second Segment July 10, 201 –August 5, 2017
Program Scheduled Days: Monday-Friday 9:00 am -3:30 pm

I understand all reasonable safety precautions will be taken at all times by the Changing “Life, Education Initiative Inc. and its agents during the events and activities. I authorize any treatment by accredited hospital and/ physician deemed necessary for my child /ward in case of an emergency. I understand the possibility of unforeseen hazard and know the inherent possibility of risk. Whenever feasible and possible the events the Leaders or Instructors will attempt to contact me for guidance and direction and will attempt to allow me to speak with the health care provider prior to any procedure or treatment.
I understand I am liable and agree to pay all cost and expenses incurred in connection with such medical and dental services rendered to my child/ward pursuant to this authorization.
Should it be necessary for my child/ward to return home due to medical reason, I shall assume all transportation costs.
I also give permission for my child/ward to ride in any vehicle or bus designated by the event leaders or instructors in whose care the minor has been entrusted while attending and participating in activities sponsored by Changing Life, Education Initiative, Inc.
The Changing Life Education Initiative Inc. is pleased to provide programs and activities as part of its summer/fall education and mentoring programs. Participation in programs and activities is contingent upon the participant’s appropriate moral and ethical behavior. Any participant not conducting himself/herself in this manner at any program or activity will be required to leave the program or activity at the expense of the parent/guardian when so informed by the event leaders or instructors in whose care the minor has been entrusted
I have reviewed the expectations listed on the back of this permission slip and agree that my child/ward will comply with them. I also acknowledge that if my child/ward has to return home early for discipline violations it will be at my expense. I agree to not hold liable Changing
Life Education Initiative, Inc. or LEO HIGH SCHOOL, leaders, employees and volunteer staff for damages, losses, diseases, or injuries incurred by my child /ward.

Payment and Deposits:

All deposits are final and will not be refunded, if a payment is made for any session and the student starts attending camp, they are no longer eligible for a refund of any amount. If student’s behavior causes them to be removed from the camp, they forfeit the camp fees and will not receive any refunds. If a student has paid for their camp fee but never attend the camp, they are entitled to a refund of their fees paid minus the $50 deposit. If a student starts attending camp and is released from the program for disciplinary action or failure to return to cam, no funds will be refunded.
While participating in any class or workshop, event leaders and instructors have the following expectations of all participants.
 Positively represent the Changing Life, Education Initiative, Inc., our community and yourself though appearance and actions.
 Attend all activities
 Maintain a reasonable noise level.
 Show respect for others.
 No inappropriate language or gestures
 Dress appropriately adhere appropriate length for short skirts and dresses no revealing tops, etc.; Males –no sagging pants or shorts showing underwear, etc.
 Do not bring buy, or use tobacco, alcohol, or illegal drugs.
 Program preference: Gym shoes (Flip Flops are not allowed because students have sports activity each day.)22, 20170172770

EMERGENCY CONTACT
PARENT/ GUARDIAN NAME *
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STUDENT NAME *
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ADDRESS, CITY,ZIP CODE *
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DATE *
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(W) PHONE NUMBER *
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(H) NUMBER *
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(C) NUMBER
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RELATIONSHIP TO YOUTH *
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ADDITIONAL CONTACT NAME *
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PHONE NUMBER *
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ADDITIONAL EMERGENCY CONTACT
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PHONE NUMBER
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