Kids Rethink New Orleans SchoolsRegistration for Summer Leadership Institute

Summer Leadership InstituteJune 23 – July 25, 2014

Andrew H. Wilson Charter School

Family Orientation Party: Thursday, June 12th Day of Action: Thursday, July 25th

Student Information

Name:_______________________________________________________________________________________________ First Name Last Name

Date of Birth: ____ /_____ /_______ Gender: __________ Age: _____

Grade entering in Fall ‘14: ___ (program is open to rising 5th-9th graders) School Attending in Fall ’14:_________________

Medical Information

Primary Doctor: _______________________________________ Phone # ( _______ ) ________ --- ______________

Primary Dentist: ______________________________________ Phone # ( _______ ) ________ --- ______________

Allergies: _____________________________________________ Medication(s) :______________________________________Special Alerts/Restrictions:___________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

Family InformationSTUDENT CONTACT INFORMATION (if applicable)

E-mail Address: ____________________ Twitter: ____________________ Instagram: __________________ Facebook: ______________________ Cell Phone: ( _______ ) ________ --- ______________ Best way(s) to contact: _ Email _Phone _Instagram _Twitter _Facebook

Guardian/ Adult Contact:_____________________________________________________________________________ First Name Last Name

Relationship:_____________________________________________ E-mail Address: _______________________________________ Home Phone: ( _______ ) ________ --- _________________ Additional Phone: ( _______ ) ________ --- __________

Address: ____________________________________________________________________________________________________________________ Street City State Zip

Best way(s) to contact: __Email __Phone _Text message Best time(s) to contact: ________________________________________

Emergency Contact:_____________________________________________________________________________ First Name Last Name

Relationship:_____________________________________________ E-mail Address: ________________________________________ Home Phone: ( _______ ) ________ --- _________________ Additional Phone: ( _______ ) ________ --- ___________

Kids Rethink New Orleans SchoolsRegistration for Summer Leadership Institute

Address: ____________________________________________________________________________________________________________________ Street City State Zip

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Program InformationPrevious Involvement with Rethink:

__ Attended summer program __ Architecture Committee__ Food Justice Committee __Garden Committee__Restorative Justice Committee __Rethink Club @ ________________Media Team __No previous involvement

How did you hear about Rethink? _____________________________________________________________________

Transportation preference: __ Rethink bus __ Car rider (drop off from 8am-9am, pick up at 3pm)

Registration Fee:We are asking Rethink families to contribute to the cost of the Summer Program on a sliding scale from $20-$100. A volunteer option is also available for families that are not able to contribute financially.

I would like to: __ Pay $_____ by check (included with registration)__ Pay $_____ in cash (you will receive a call from a Rethink staff member to set up payment)__ Volunteer 5 hours with the Rethink Summer Program

Your child’s spot in the summer program will not be reserved until registration fee has been received.

Additional Volunteer Opportunities: __ I will volunteer to provide lunch for one or more days of the summer program__ I will volunteer at the Day of Action on Thursday, July 25th __ I will provide carpool rides for another Rethinker in my neighborhood__ I will help coordinate the Family Welcome Party

Attendance:Please list any dates that your child will be out of town or unable to attend the summer program.________________________________________________________________________________________

PERMISSIONS I give permission for my child to participate in the Kids Rethink New Orleans Schools Summer Leadership Institute. Programming will take place June 23 – July 25, 2014 (with June 16-20 orientation for High School interns).

I give my permission for the use and reproduction of photographs and video of my child, and photos and reproductions of my child’s work created by or through the program.

I understand my child will be traveling with personnel affiliated with Kids Rethink New Orleans Schools. Unless said Rethink personnel do something that is considered intentional or grossly negligent under Louisiana law I am holding them Rethink, its board of directors, employees, agents and representatives, harmless for any injury my child suffers, up to and including death. Furthermore, I realize it is my sole responsibility to have and use medical insurance for any medical needs my child may have. Should medical attention be required I give the Rethink personnel the right to procure it for my child at any medical facility available at my expense.Parent/Guardian Signature: _____________________________________________ Date: ____ / ____ / ________

Please mail this form and registration fee ($20-$100) to: Kids Rethink New Orleans Schools

1001 S. Broad St, Ste 206, New Orleans, LA 70125Or email to rachel@therethinkers.org

Kids Rethink New Orleans SchoolsRegistration for Summer Leadership Institute

Returning Rethinker Early Application Deadline: April 30th

We have limited space in the summer program. Returning Rethinkers who submit completed applications with registration fee by April 30th will be given first priority. After April 30th all applications will be accepted on a rolling basis regardless of previous experience with Rethink. Spot can be guaranteed if registration fee has been received or volunteer arrangement has been

completed.