2025 Rising Rox Stars Summer Camp
The 2025 Rising Rox Stars Summer Camp is July 14 to August 7, 2025 (Monday through Thursday) at Roxboro Road Elementary (RRE) and Roxboro Road Middle (RRM) Schools. The camp is only for students who will be in grades K to 7 grade at RRE and RRM in the 2025-2026 school year. The camp hours are 8:30am to 12:30pm. Breakfast, lunch and transportation are provided. Space is limited. Please register by June 13. Questions? Please contact Chau Ly at 315-263-5284 (call/text) or cly@nscsd.org. 
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Email *
Student LAST Name *
Student FIRST Name *
Student DATE OF BIRTH *
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Student's SCHOOL *
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Student's GENDER *
Student's STREET ADDRESS *
Student's CITY *
Student's ZIP CODE *
Student's STATE *
Phone Number (home or cell). Numbers only, no dashes. Example: 3152182034 *
EMAIL *
Primary Language Spoken At Home *
Required
What grade will your child be in September 2025 (at the start of the new school year)? *
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Studen'ts Race/Ethnic Group *
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Parent LAST Name *
Parent FIRST Name *
Parent Phone Number (home or cell). Numbers only, no dashes. Example: 3152182034 *
Please check the week(s) your student will attend the summer camp (Monday-Thursday).  *
Required
Please pick the type of activities your child likes the most. *
Will your student need bus transportation to and from the program?  *
Required
Please list at least 2 emergency contact names and phone numbers (including relationship to student). *
If I am not available during emergencies, my child may be released to one of the following individuals. Please list name, phone number and relationship to student.
Please list important medical information about your student (i.e. allergies, asthma, etc...). Please indicate if your child has an IEP or a 504 plan.   *
I give my child permission to participate in the 2025 Summer Rising Rox Stars Program (funded by the 21st Century Community Learning Centers Grant). *
I consent to emergency medical treatment for my child.
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I consent for my child to participate in interviews, the use of quotes, and the taking of photographs, movies, or videotapes by the program. I also grant the program the right to edit, use, and reuse said products for non-profit purposes including use in print, on the internet, and all other forms of media. I also hereby release the program and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.
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I consent for my child to take part in field trips, away from the program site, under supervision.
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I understand that information regarding my child’s special learning needs will be shared by my child’s school of enrollment with Rising Rox Stars program staff on a need-to-know basis for my child’s educational benefit.
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If at any time I change my mind about my child’s participation (any or all aspects) in the program, I will contact the program director or site coordinator.
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I understand that my child’s academic, behavioral, attendance, and engagement information will be shared with the New York State Education Department and its lawful contractors, to measure and evaluate the quality and implementation of the Rising Rox Stars Program which is funded by the 21st Century Community Learning Center (21st CCLC) grant as well as the effectiveness New York State’s program in supporting student growth, as required by Title IV, Part B of the Every Student Succeeds Act (ESSA) [see generally sections 4205 (b) and 4203 (14)].
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I understand that my child and I may be asked to participate in surveys and/or interviews about the Rising Rox Stars Program (funded by the 21st CCLC grant) and its effects.
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By electronically signing below, I certify that all information above is true and correct to the best of my knowledge. Write in first and last name.
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Date of eletronic signature.
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