Application for Summer Camp Enrollment

Today’s Date_____________
NAME OF STUDENT ___________________________________ AGE __________
ADDRESS___________________________________________________________
PHONE (HOME) _______________________ (CELL) __________________________
GRADE____________________ PREVIOUS SCHOOL ________________________
STUDENT’S PARENT(S), LEGAL GUARDIAN(S)
NAME OF MOTHER______________________________________________
NAME OF FATHER_______________________________________________
SISTER(S) ______________________________________________________
BROTHER(S) ____________________________________________________
RELATIVES(ONLY THOSE INVOLVED IN STUDENT’S SCHOOL AFFAIRS) ________________________________________________________________

STUDENTS HEALTH(LIST ANY AND ALL CONCERNS AND/OR ILLNESS, DIAGNOSIS OR KNOWLEDGABLE) __________________________________________________________________
DID YOUR STUDENT HAVE PREVIOUS ACADEMIC PLAN?     YES OR NO (CIRCLE ONE)
DOES YOUR STUDENT TAKE ANY MEDICATIONS DAILY?        YES OR NO (CIRCLE ONE)(YOU (THE PARENT/LEGAL GUARDIAN) WILL BE RESPONSIBLE FOR ADMINISTERING MEDS THROUGHOUT THE DAY, THE SCHOOL, BY LAW, CAN NOT BE RESPONSIBLE FOR THE INTAKE/DIGESTION OF ANY PRESCRIBED OR NON-PRESCRIBED MEDICATION OF THE STUDENT).
WILL THE STUDENT NEED ASSISTANCE FOR ANY DUTIES?     YES OR NO(CIRCLE ONE)

STUDENT’S TRANPORTATION – CAR RIDER OR BUS RIDER(CIRCLE ONE)

STUDENT SCHOOL CARE - BEFORE, AFTER, BOTH(CIRCLE)

STUDENT’S LUNCH – SCHOOL, HOME(CIRCLE)

STUDENT’S TUITION – FULL PAY, SCHOLARSHIP, GRANT, FINANCED (CIRCLE)

HOW DID YOU HEAR ABOUT US? NEWSPAPER, INTERNET, BILLBOARD, FRIEND ______________________________________ (CIRCLE AND LIST NAME OF SOURCE)

NAME OF PERSON FILLING OUT FORM ______________________________________

SIGNATURE ____________________________________________________________

St. Lavere’s Preparatory School and Summer Camp admits students and employs staff/administration of any race, color, national and ethnic origin to all rights privileges, programs and activities generally accorded or made available to students on our campuses. We do not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies, admissions policies, scholarship programs, athletic and other school-administration programs.