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Summer STEM Academy Registration
Jumoke Academy Grades 5-8 | Summer 2019
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Parent / Guardian Information
Please provide information about the scholar's primary adult contact
Parent / Guardian Information
Please provide information about the scholar's primary adult contact
Primary Parent or Guardian First Name
*
Your answer
Primary Parent or Guardian Last Name
*
Your answer
Email Address
*
Your answer
Cell Phone or Home Phone #
*
Your answer
Relationship to student
*
Mother
Father
Legal Guardian
Grandmother
Grandfather
Other:
Please let us know your child's basic information
Student First Name
*
Your answer
Student Last Name
*
Your answer
Student Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Other:
What is your child's primary spoken Language?
*
English
Spanish
Other:
What school will your child attend in the 2019-2020 school year?
*
Choose
Jumoke Academy Honors - Science Math and Research Technology (JAH-SMaRT)
Jumoke Academy Honors at The Hartford Conservatory (JAH-HC)
Other...
*This year's Summer STEM Academy is only open to currently enrolled Jumoke Academy scholars.
Grade Attending in 2019-2020
*
Choose
5th Grade
6th Grade
7th Grade
8th Grade
Student's Home Street Address
*
Your answer
City
Your answer
State
*
Your answer
Zip code
*
Your answer
Emergency Contact Information
Please tell us who to contact in case of emergency. The primary adult listed above will be the first emergency contact.
Emergency Contact #2 Full Name
*
Your answer
Emergency Contact #2 Phone number
*
Please include area code
Your answer
Emergency Contact #2 Relationship to student
*
Mother
Father
Legal Guardian
Grandmother
Grandfather
Other:
Emergency Contact #3 Full Name
Your answer
Emergency Contact #3 Phone number
Please include area code
Your answer
Emergency Contact #3 Relationship to student
Mother
Father
Legal Guardian
Grandmother
Grandfather
Other:
Clear selection
Basic Medical Information
If emergency medical attention is needed send student to:
*
Choose
St. Francis Hospital
Hartford Hospital
CT Children's Medical Center
Authorization for administration of Medicine by school personnel
Will your child need medicine to be given during the school day? Please answer below...*Additional Paperwork may be required.
Does your child require medicine(s) to be administered during the school day?
Yes
No
Other:
Does your child have any allergies or health concerns? If so please provide detail below...
*
Yes
No
If you answered Yes, to the question above, please provide detail
Your answer
Media Release
Do you give permission for photos that may be taken of your child during the Summer STEM Experience to be used by Jumoke Academy for district communication/ media purposes?
*
Yes
No
Option 1
Clear selection
After Care Needs
Jumoke Academy will have optional After Care available for an extra fee of $10.00 p/week each child. Aftercare will be at 250 Blue Hills Ave. from 4-5pm.
Some additional paperwork may be required.
Will you be interested in After Care services?
Yes, I am interested in After Care
No, I will not need After Care
Clear selection
Care 4 Kids
What is Care 4 Kids? Care 4 Kids helps low to moderate income families in Connecticut pay for child care costs. This program is sponsored by the Connecticut Office of Early Childhood.
Will you be completing a Summer Care4Kids Form?
*
Yes
No
I certify that the information contained in the above application is truthful and accurate, and that by submitting this application, I am requesting that my child be accepted into the Jumoke Academy Summer STEM Academy at Goodwin College.
*
Yes, I certify
Submit
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