Results Learning - 2019 C.E.O. Executive Functioning Skills Summer Camp

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NOTE: Please be sure to select the correct session from the choices below.

I am registering my child for: *

Session #1: June 15th to June 26th, 9:00 AM -12:00 PM for incoming 8th-10th grade

Session #2 : June 15th to June 26th, 1:00 PM – 4:00 PM for incoming 6th-7th grade

Session #3: July 6th to July 17th, 9:00 AM -12:00 PM for incoming 6th–7th grade

Session #4: July 6th to July 17th, 1:00 PM – 4:00 PM for incoming 8th-10th grade

Student's First and Last Name (If enrolling more than one child, please register separately.) *

Grade Student Entering *

Grade 6 - Session #2 or #3 only

Grade 7 - Session #2 or #3 only

Grade 8 - Session #1 or #4 only

Grade 9 - Session #1 or #4 only

Grade 10 - Session #1 or #4 only

Student Gender *

Female

Male

Other:

Current School Your Child Attends *

Parent or Guardian First and Last Name(s) *

Parent or Guardian Email(s) *

Parent or Guardian Phone Number(s) *

Full Address (Street, City, State and Zip Code) *

Payment: Option 1: Make full payment $1050.00. Option 2: To secure a camp spot a deposit of $250.00 must be received within 10 days of registration completion. Final payment is due two weeks prior to camp start date. (Information on payment process will be included in a follow-up email.) *

Option 1: Make Full Payment of $1050.00

Option 2: Deposit Payment of $250.00 with final payment due two weeks prior to camp start date

Emergency Contact(s) First and Last Name, Relationship and Phone(s) *

Doctor's Name & Phone Number *

Medical Insurance Provider and Policy Number *

Pick-up information *

I will pick-up my child after camp.

I authorize my child to walk home after camp session ends.

My child may be picked-up by another individual(s). (Name(s) and phone contact(s) must be provided below.)

Other:

Required

Please list names of any individuals authorized to pick-up your child. Include phone numbers. Note: Designated person will be asked to provide a license for identification and, if need be, the password provided below. *

Please provide us with a password that your child knows and can be shared with emergency contacts and anyone who might be picking up your child. *

Dietary restrictions *

None

Vegetarian

Vegan

Kosher

Gluten-free

Other:

Please list all allergies (food, medicine, etc.). *

Parent/Guardian Statement of Understanding. The following information is important for the safety and protection of your child. Please read this information and authorize below. *

I understand that my child will not be allowed to leave the program with an unauthorized person. Any person authorized to pick up my child must be listed above.

I understand that I am not to leave my child at Results Learning, LLC or program site unless a Results Learning, LLC Camp staff member or volunteer is there to receive and supervise my child.

Sign-in/Sign-out sheets are available as you arrive at the program area. I understand that it is my responsibility (or the responsibility of an authorized person) to sign my child in each morning and sign my child out before leaving in the afternoon.

I understand that Results Learning, LLC is mandated to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation.

I understand that Results Learning, LLC staff and volunteers are not allowed to babysit or transport children at any time outside the Results Learning, LLC facilities and program unless noted on a field trip day. If a violation of this policy is discovered, Results Learning will take immediate disciplinary action toward staff and volunteers.

I understand that if my child is removed from the program as described in the accompanying “Behavior Agreement”, I am not entitled to a refund of any portion of the registration fees.

By checking this box, you confirm that you have read and understand the statements above regarding Results Learning, LLC Policies and Procedures.

Required

BEHAVIOR AGREEMENT - At Results Learning, LLC C.E.O. Summer Camp, we take learning very seriously. Results Learning, LLC C.E.O. Summer Camp is a place for learning, creating memories and life-long experience with skills to become successful. Our efforts in conjunction with the children and parents will allow a fun and healthy environment for everyone by following some simple, but effective rules. Failure to abide by this agreement could result in the removal from this program. All incidents will be recorded and put in the student's file. 1st Incident - Verbal Warning. 2nd Incident - Meeting with Parent/Guardian. 3rd Incident - Removal from program. Notwithstanding the foregoing, Results Learning, LLC may require removal from the program after occurrence of the 1st incident if the severity of the incident is such that Results Learning, LLC, in its sole discretion, determines that it cannot guaranty the safety of your child or other participants, staff, volunteers or third parties. Below is a list of expectations which requires your approval. Please read it with your child and be sure you both understand it in its entirety. This will help us have a great experience at Results Learning, LLC CEO Summer Camp. Thank you! *

I will listen and follow directions of the staff.

I will keep my hands to myself.

I will use a calm voice when speaking.

I will use appropriate language at all times.

I will respect other people’s belongings.

I will not swear at or make negative remarks about others in the camp.

I will ask for permission at all times.

By checking this box, you confirm that you and your child have read and understand the statements above regarding Results Learning, LLC Policies and Procedures Regarding Behavior.

Required

STUDENT TECHNOLOGY USE POLICY FOR CELL PHONE-LAPTOP-TABLETS - To access policy click this link: https://tinyurl.com/yak5hz4d *

By checking this box, you confirm that you have accessed the policy through the above link, read and understand all statements regarding Results Learning, LLC, Student Technology Use Policy for Cell Phone/Laptop/Tablets

Required

PARTICIPANT WAIVER OF LIABILITY AND RELEASE AGREEMENT ACKNOWLEDGEMENT OF - To access waiver click this link: https://tinyurl.com/yck7uug4 *

By checking this box, you confirm that you have accessed the policy through the above link, read and understand all statements regarding Results Learning LLC, C.E.O. Summer Camp Participant Waiver of Liability and Release Agreement

Required

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