Middle School [About Nature: Writing, Walking and Making] Summer Enrichment Program 2021 Registration Form

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Students will be provided materials for the course as needed.

This creative writing and making class is centered on the skills of observation and cultivating curiosity. Students will experience a small class focused on expressing their values and experiences that relate to nature, while learning about local plants and animals.

**The class will be held in accordance with 4J School District COVID safety protocols, including the practice of social distancing and required PPE.**

Teacher: Meredith Coelho
Dates: August 16th- 20th,
Times: 9am - 1pm
Location: Roosevelt Middle School
Grades: Those entering 6th- 9th grade

Email *

Student's FIRST Name

Student's 4J Identification Number

Middle School Student Will Be Attending in FA2021: *

Arts and Technology Academy

Cal Young Middle School

Kelly Middle School

Kennedy Middle School

Eugene Online Academy

Madison Middle School

Monroe Middle School

Roosevelt Middle School

Spencer Butte Middle School

Other:

Student Home Address: *

Example: 200 N Monroe St., Eugene, OR 97402

Parent / Guardian Last Name: *

Parent / Guardian First Name: *

Parent/Guardian Phone Numbers - Cell, Home, Work *

Please list all available numbers. Examples: 541-790-7700 (Cell) 541-790-7701 (Home) 541-790-7702 (Work)

Name of Emergency Contact : *

Emergency Contact Relationship: *

Example: Grandmother, Aunt, Family Friend, etc.

Emergency Contact Phone *

Example: 541-790-7700

Health Conditions: Please indicate if any of these or other conditions apply to your child.

Asthma (please list more specific information below)

Diabetes (please list more specific information below)

Heart Condition (please list more specific information below)

Hearing Loss (please list more specific information below)

Orthopedic Condition (please list more specific information below)

Mobility Limitation (please list more specific information below)

Severe Bee Sting (please list more specific information below)

Seizures (please list more specific information below)

Severe Food Allergy (list which food or foods below)

Speech Disorder (please list more specific information in prompt below)

Other Allergies (please list more specific information in prompt below)

Other:

Please indicate if your student is supported by

IEP

504

As appropriate, please provide more specific information on health conditions, including required accommodations.

If the student requires prescription medication while attending this Summer Intensive Course, please list.

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