LEAP Summer Application
This application is for Eaton Academy's LEAP Summer Program. Please fill out this application in order for your high school student or young adult to attend one or both summer sessions. Summer sessions are June 10 - 28 and July 8 - 26, Monday through Friday, 9:00 to 3:00. Please contact mvidito@eatonacademy.org for more information.
Email address *
Which Session(s) are you applying for? *
Required
Participant's Name (Last, First, Middle) *
Your answer
Mailing Address *
Your answer
Participant's Cell #
Your answer
Age *
Your answer
DOB (mm/dd/yyyy) *
Your answer
VR Counselor (if applicable)
Your answer
Primary Caregiver (Name: First, Last) *
Your answer
Primary phone # *
Your answer
Primary contact email *
Your answer
Secondary Contact (Name: First, Last) *
Your answer
Secondary Contact phone# *
Your answer
Secondary Contact email *
Your answer
Other Emergency Contact (Name, #, email)
Your answer
Any physical, visual, auditory, or motor difficulties? *
If yes, please explain
Your answer
Is the participant in good health? *
If no, please explain
Your answer
Please list all medications taken by participant: *
Your answer
Does the participant have any allergies? If yes, please list. *
Your answer
Name and number of participant's Primary Doctor: *
Your answer
Does the participant use any type of auditory or visual device? *
Your answer
Has the participant ever been involved with law enforcement authorities? *
If yes, please explain.
Your answer
Has the participant ever been subject to major disciplinary action (suspension or dismissal) in any school or employment setting?
If yes, please explain.
Your answer
How will the participant arrive and depart? Please list names of all individuals that may transport participant to and from the program. *
Your answer
Please check "yes" if you would like LEAP to obtain identification from individuals who may pick up your participant.
May we take pictures of or film your participant for publicity and social media purposes? *
Dates: First Session: June 10 – June 28 and Second Session: July 8 – July 26 Hours: 9:00 a.m. – 3:00 p.m. Requirements: Participants must be at least rising high school Freshman through young adult. $3,100.00 per session due by May 31, 2019 (for First Session), and by June 30, 2019 (for Second Session)
1. Tuition must be received according to the above schedule and is completely non-refundable.
2. The Parent and the Participant acknowledge reading and will abide by Eaton Academy’s regulations and policies as stated in the Parent and Student Hanbook (available online at www.EatonAcademy.org). Any violation or breech thereof by the Participant (or the Parent) may result in disciplinary action, including suspension and dismissal from LEAP, with no refund of tuition. These regulations are incorporated into this agreement. Eaton Academy reserves the right, from time to time, to change, amend, add to, or delete portions of the Regulations as it deems necessary.
3. The Parent and the Participant understand, acknowledge, and agree that the Participant may be riding with other Program participants and using public transportation during the LEAP Summer Program.
4. The Parent and the Participant understand, acknowledge, and agree that the Participant may be transported by LEAP staff members in a voluntary transportation arrangement.
5. The Parent and the Participant understand, acknowledge, and agree that the participants will prepare lunch on a daily basis - a menu for which will be provided in advance. Peanut butter and jelly will be available each day. If the Participant has specific dietary restrictions or allergies, they must be listed on this application/agreement, and the Participant will need to bring his/her own food.
6. The Parent and the Participant understand, acknowledge, and agree that they will adhere to the guidelines put forth in the Eaton Academy LEAP Parent and Student Handbook. In particular they understand, acknowledge, and agree that Eaton Academy maintains a zero tolerance for drugs, alcohol, tobacco, weapons, viloence, threats, and bullying. This zero tolerance includes the possession and/or use of any of the above items as well as the possession and/or use of any paraphernalia associated with any of the above items. Further, inappropriate conversation about and/or an attitude that promotes the use of any of the above items is subject to the zero tolerance policy. The Parent understands, agrees, and acknowledges that as part of this zero tolerance policy the Participant’s enrollment can be terminated at Eaton’s discretion for whatever is, in Eaton’s opinion alone, a violation of this zero tolerance policy. Should the Participant’s enrollment be terminated, all tuition due Eaton Academy must be paid by the Parent. Eaton Academy also maintains a zero tolerance policy toward the inappropriate use of technology.
7. Participants will be performing various culinary tasks such as, but not limited to: cutting, chopping, slicing, baking, and broiling. The Parent and the Participant understand, acknowledge, and agree that these tasks can be hazardous and that the Parent and the Participant assume full risk and liability associated with such tasks.
Please read this statement carefully and sign below:We have completed this application to the best of our ability, and we hereby certify that all statements made are true and accurate to the best of our knowledge. Additionally, we hereby acknowledge reading, understanding, and agreeing to the terms, conditions, permissions, and expectations contained in this application, including the Eaton Academy LEAP Parent and Student Handbook. We hereby convenant and agree that Eaton academy, Inc., its owners, officers, instructors, agents, and staff (the “Released Parties”) shall not be liable for any damages including, without limitation, compensatory damages, punitive and exemplary damages, pain and suffering, and damage to property which may in any way result from or arise out of the transportation or culinary activities. We hereby fully and forever release and discharge and covenant not to sue the Released Parties for any and all claims, demands, damages, rights of action or causes of action, present or future, whether the same be known or unknown, anticipated or unanticipated, resulting from or arising out of the transportation or culinary activities while the Participant attends the LEAP Summer Program.
Participant's Signature *
Your answer
Date *
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Parent/Guardian's Signature *
Your answer
Date *
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A copy of your responses will be emailed to the address you provided.
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