Farrell Area & Sharon City School Districts
21st Century CCLC C.O.O.L. 2018 Summer Enrollment Form
(Please complete both sides of this form.  Please print unless otherwise indicated.)

Please check all weeks you are registering your child for

 	   Monday June 11 - Friday June 15	 	
 	   Monday June 18 - Friday June 22	 	
 	   Monday June 25 - Friday June 29	 	

Monday July 2 - Friday July 6 (NO COOL on July 4) Monday July 9 - Friday July 13
Monday July 16 - Friday July 20

Each day will run from 9:00 am-1:00pm.
The location will be the school the child is enrolled in for the 2018-19 school year. Grades 5-9 Is your child currently enrolled in the COOL after school program?		Yes		No
Student Information
Student Name:	Birth date:  	
Grade (2018-19 school year)	School:  	
Parent(s)/Guardian(s) Name:   			 Home Address:  		  Home Phone:	Alternate/Work Phone:  	
I authorize my child to participate in activities provided by the 21st Century Community Learning Center Summer C.O.O.L. Programs.

X		 (Parent/Guardian Signature)

Medical/Emergency Information
Does your child have any allergies or other conditions that our C.O.O.L. staff should be aware of?
 	 Yes	No Please Explain:

Is your child currently taking prescribed medication?	Yes	No Please Explain:

My child’s Health Insurance is provided by:
 	 My Health Insurance
 	 School Insurance

Family Physician:	Phone:  	

In case of an accident, injury or illness, I hereby authorize the responsible school person to take my child to a physician or hospital emergency room, and I further understand that I will be responsible for all costs associated with said accident, injury or illness.

X		 (Parent/Guardian Signature)

Emergency Contact:
In the event of an emergency we will attempt to contact the parent/guardian. If we are unable to reach you, we ask that you provide an emergency contact.

Name:	Relationship:  	

Address:	Phone:  	

**The C.O.O.L. staff is not authorized to dispense medication— Please make alternate arrangements if your child requires medication during the C.O.O.L. program.

Internet Usage Authorization
Use of technology is an integral part of many of our programs. Supervised activities involving use of the Internet are included. Please sign below to allow your child to participate in supervised curriculum related Internet usage.  Casual e-mail and use of chat rooms will be prohibited.

X		 (Parent/Guardian Signature)

**There will be NO transportation to and from the school location for the summer camp program.

Field Trip Authorization
Our Summer Program will involve field trips and we will utilize transportation provided through a local bus company and district owned vans. For out of town field trips specific advance notice will be provided and permission slips required prior to the scheduled trip.

 	 I authorize my child to be transported by contracted carrier to supervised off-site activities scheduled through the Summer C.O.O.L. programs.

X		 (Parent/Guardian Signature)
Funded in full or in part with a grant provided by the Pennsylvania Department of Education