Mosaic Sign-Up ~ Fall 2018
Student's Name *
Your answer
Grade *
Parent / Guardian Name *
Your answer
Street Address *
Your answer
Email Address
Your answer
Home / Work Phone: *
Your answer
Cell Phone:
Your answer
Does your child have any allergies / health conditions? *
Your answer
Does your child have an IEP or behavior management plan? *
If yes, yes, please provide the name of their case manager so we can make necessary arrangements for your child’s success.
Your answer
Emergency Contact Name (OTHER than parent / guardian) *
Your answer
Emergency Contact Phone: *
Your answer
Discipline: "Three Strikes” and you’re out for minor offenses. “One Strike” and you’re out for any physical/violent actions towards students/staff. By selecting "yes", I understand that all school rules apply accordingly. *
Students are not allowed to switch clubs after the first day. It is important for students to take their choice of summer program(s)seriously. It is their responsibility to attend regularly. If a student misses more than (3) times, they will no longer be able to attend. Refunds will not be given. Please check "yes" if the importance of attendance is understood. *
MEDIA RELEASE: My child may be interviewed /photographed /videotaped by the news/media/school or school district which may result in print, video, or web publication. *
MEDIA RELEASE: MAUMS or the SVSU may feature my child’s school work. *
I acknowledge that students must be picked up no later than 4:55 pm. Mosaic Program does not provide student supervision beyond 5:00 pm. *
Mondays ~ 2:45 - 4:45
Tuesdays ~ (Note Program Times)
Wednesdays ~ 2:45 - 4:45
Thursdays ~ 2:45 - 4:45
The fee is $20.00 for each program that a student is signed up for. Which means, each box checked above is $20.00 per check. Payment can be sent to MAUMS, 747 East Road, Bennington, VT 05201, Attn: Mosaic. Scholarships are available. No students will be turned away!
I, the parent / guardian of the child listed under "Student Name", agree that I have answered the above questions accurately to the best of my knowledge. By selecting "Yes", I agree that I have reviewed this form and my child may attend the selected Mosaic Programs. *
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