Student Life at Excelsior Preparatory School

Summer Program Registration Form

Please fill in the following information to register your child for our summer program.

  1. Student's Name*
    Student's full name is required
  2. 2016-17 Grade Level*











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  3. *
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  4. First Parent Name*
  5. First Parent's Home Phone No.
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  6. First Parent's Cell Phone*
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  7. First Parent's Email*
    Please enter a valid email address
  8. Second Parent's Name
  9. Second Parent's Home Phone
  10. Second Parent's Cell Phone
  11. Second Parent's Email
    please enter a valid email address
  12. Daytime emergency names & phone numbers. At least one is required.
  13. 1.*
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  14. 2.
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  15. Please list persons, if any, to whom you are permitting Excelsior Artz Preparatory School to release your child without prior verbal consent in the section below:
  16. 1. Name / relationship with child / Phone Number:
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  17. 2. Name/relationship with child/phone number
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  18. 3. Name/relationship with child/phone number
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  19. 4. Name/relationship with child/phone number
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  20. Signature of Consent
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  21. Date
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  22. List any allergies that your child possesses that you are aware of:
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  23. Child's Primary Physician Name & Phone*
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  24. **Immunization records are required for all non- EAPS students (including newly enrolled students) to complete registration. This form is also required even if you submitted one last summer**
  25. In addition to the Spanish Immersion program, indicate any of the additional remedial needs below:
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  27. I am aware that enrollment in Excelsior Artz Preparatory School’s Summer School/Camp program does require my child to be actively involved in many hands on activities both on the school’s campus and away from the school’s campus(during field trips). Due to the nature of the various activities within Excelsior Artz Preparatory School’s Summer School/Camp Program, regardless of the high degree of supervision, there is a potential for injury during any activity. I am enrolling my child in the summer program offered and on behalf of my child and myself do assume the risks associated with the activities therein. I hereby, release and agree to hold harmless Excelsior Artz Preparatory School, Inc. its officers, trustees, directors, employees, and agents from, and waive any claim, as to any injury or other harm that may happen to me as a result of injury or harm suffered by my child. This indemnity agreement specifically includes but is not limited to (a) any claim of negligence or negligent supervision against Excelsior Artz Preparatory School, its officers, trustees, directors, employees, and agents; (b) any injury or harm that may occur while my child is riding in a vehicle owned or leased by Excelsior Artz Preparatory School Inc., (c) any injury or harm that may occur while my child is otherwise on Excelsior Artz Preparatory School’s property, before or after any of the scheduled program hours for any reason whatsoever.

    I am responsible for the payment of applicable fees stated in the academic agreement. In cases where more than one party will be sharing the expenses of the fees, each party who signs the application hereby agrees to be responsible for all such fees on or before the assigned due dates.

    All rules, guidelines, policies, and procedures published in the Excelsior Artz Preparatory School Parent/Student handbook apply to the Summer School /Camp programs. I understand that I will not be issued a refund if my child commits any infraction that results in suspension or expulsion, or the withholding of a scheduled school activity or excursion. Once reservations are made and fees are paid, I realize that they are non-refundable and make-up days are unavailable. I further understand that refunds will not be issued in the event of a natural disaster, such as a severe storm.

    I hereby grant Excelsior Artz Preparatory School permission to use any individual or group photographs taken of my child for publicity or brochure purposes.

    I hereby release and hold harmless Excelsior Artz Preparatory School, the Summer School/Camp Programs, its officers, trustees, directors, employees, and agents from any responsibility for any lost stolen or damaged personal property that my child brings to school.

    The signatures of both parent and legal guardian(s) are required below:
  28. Parent One Name*
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  29. Parent Two Name
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  30. Guardian's Name
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  31. *
    Please enter the two words in the box above