Summer 2024 Pirate Quest Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill out the form completely. Anything not completed may disqualify a student from participation in Pirate Quest Summer Program. Your application will be checked for qualifying criteria. If your child qualifies for Pirate Quest Summer Program, you will be notified by April 15, 2024. If your child qualifies for Pirate Quest Summer Program but your application was received after all spots have been filled, your child will be placed on a waiting list. If a spot becomes available, you will be notified.

Email *

Untitled Title

Summer Program Site *

Student's Last Name *

Student's First Name *

Gender *

Race/Ethnicity *

Grade Completed (23/24 School Year) *

Parent's Name *

Address *

Phone Number *

Will your child ride the bus in the morning? *

Yes- If Yes please answer next question

Will your child ride the bus in the afternoon? *

Yes- If Yes please answer next question

Does your child have any allergies? *

Yes- If Yes please answer next question

What allergies does your child have?

Does your child take medication? *

Yes- If Yes please answer next question

List all medications that your child takes.

Emergency Contact Name *

Emergency Contact Phone Number *

I give permission for my child’s photo or video to be used on the social media site, flyers, and other publicity materials. *

Yes

I understand the following procedures will be followed consistently in the event participants behave unacceptably:

a) First offense: The Lead Teacher will discuss the problem with the student and the student’s parent/guardian.

b) Second offense: The Program Director will discuss the problem with the student and the student’s parent/guardian.

c) Third offense: The Program Director will discuss the problem with the student and the student's parent/guardian and the student will be dismissed from the program.

NOTE: Serious or disruptive/destructive behavior that interferes with normal Program operation will not be tolerated and will result in immediate dismissal with no previous notice to a parent/guardian.

Any inappropriate behavior by a parent, including verbal abuse of a student or staff member or confrontations with staff members in the presence of a student, is grounds for termination of the family’s participation in the Program without notice. This program is not required and is a privilege for those that attend. *

Yes

I understand the following procedures will be followed consistently in the event participants behave unacceptably:

a) First offense: The Lead Teacher will discuss the problem with the student and the student’s parent/guardian.

b) Second offense: The Program Director will discuss the problem with the student and the student’s parent/guardian.

c) Third offense: The Program Director will discuss the problem with the student and the student's parent/guardian and the student will be dismissed from the program.

Yes

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Poteau Public Schools. Report Abuse

Forms