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Together we can and do make a difference!The Globe Issue No. 14 March 28, 2019 Juan Melián Charter Oak International Academy 425 Oakwood Avenue, West Harord, CT 06110 Telephone: 860-233-8506 Fax: 860-761-1244 SAVE THE DATE!! Friday, March 29th Art Show Grand Opening 7:45-8:30 a.m. April 5th Welcoming School Meeting 8:45-10:45 a.m. Cafeteria April 8th-April 12th Spring Break No School April 19th Good Friday No School ATTENDANCE If your child will be absent or tardy from school, please call our office at (860) 233-8506 If you are put into our voicemail system, press 1 to leave a recorded message. Please include the reason for the absence. This procedure will eliminate incorrect absence reporting as well as unnecessary phone calls to your home. MOVING OR CHANGING SCHOOLS? If you have moved or are plan- ning on moving to another address, it is necessary to contact the Residency Office and inform them of your new address. You may reach them by calling (860) 561-6620 or stop by their office at the Town Hall.

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Page 1: The Globe - Charter Oak International Academy- PTOcharteroak.whps.org/uploaded/Schools/Elementary...once the eggs hatch. Nits are attached to the hair shaft and often found around

“Together we can and do

make a difference!”

The Globe

Issue No. 14 March 28, 2019 Juan Melián

Charter Oak International Academy

425 Oakwood Avenue, West Hartford, CT 06110 • Telephone: 860-233-8506 • Fax: 860-761-1244

SAVE THE DATE!!

Friday, March 29th

Art Show Grand Opening

7:45-8:30 a.m.

April 5th

Welcoming School Meeting

8:45-10:45 a.m. Cafeteria

April 8th-April 12th

Spring Break

No School

April 19th

Good Friday

No School

ATTENDANCE

If your child will be absent or tardy from

school, please call our office at

(860) 233-8506

If you are put into our voicemail system,

press 1 to leave a recorded message. Please

include the reason for the absence. This

procedure will eliminate incorrect absence

reporting as well as unnecessary phone

calls to your home.

MOVING OR CHANGING

SCHOOLS?

If you have moved or are plan-

ning on moving to another

address, it is necessary to contact

the Residency Office and inform

them of your new address. You

may reach them by calling (860)

561-6620 or stop by their office

at the Town Hall.

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Student Activities:

Monday, 4/1

Orchestra– Gr. 5 7:45am Auditorium

Tuesday, 4/2

Gr. 5 Band 7:45am Auditorium

Wednesday, 4/3

Gr. 4 Band 7:45 am Auditorium

Gr. 5 Strings Practice 8:05am Music Room

Club

Lexia Lab 8:00am Library

Thursday, 4/4

Suzuki Tour Group 8:00 am Room 160

Chorus 8:00am Music Room

Friday, 4/5

Lexia Lab 8:00am Library

Monday, 4/8

Orchestra– Gr. 5 7:45am Auditorium

Tuesday, 4/9

Gr. 5 Band 7:45am Auditorium

Wednesday, 4/10

Gr. 4 Band 7:45 am Auditorium

Gr. 5 Strings Practice 8:05am Music Room

Club

Lexia Lab 8:00am Library

Thursday, 4/11

Suzuki Tour Group 8:00 am Room 160

Chorus 8:00am Music Room

Friday, 4/12

Lexia Lab 8:00am Library

PowerSchool Parent Portal

Don’t forget to fill out the Welcome

Back forms online on your

Parent Portal:

https://powerschool.whps.org/public

LOST AND FOUND

If your student has lost anything,

remind them to check the lost and

found bin/table in the main lobby!

We donate the items every two weeks.

Friendly reminder that we will be starting postural screenings (per CT General Statutes) on 5th grade girls next month. The purpose of this screening program is early identification of spinal deformities so that treatment can be initiated to prevent, if possible, the need for surgery and the discomfort and complications which occur with these deformities. Feel free to call the health room with any questions/concerns.

Thank you!

Melissa Wren and Caitlin Manoni COIA School Nurses

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CHARTER OAK INTERNATIONAL ACADEMY

ART SHOW OPENING

Friday, March 29th, 2019

7:45 – 8:30 a.m.

The PTO is sponsoring a Family Reception

for this special opening. They will provide

light refreshments.

The art exhibit will be on display from

March 29th until the end of May.

Make sure you walk around and see what

all artists have created!

Do not miss the Coral Reef ceiling and the

Impressionist frog pond in the main

entryway!

Check out the Monochromatic Portrait

Gallery to see if you can find your child’s

self-portrait.

Note: All students must be accompanied by

an adult.

EVERYONE WELCOME!

Please join us to marvel at the beautiful artwork

our children have been working on this year. They

will proudly display their work in our Hallway Art

Gallery and 3D art in the Media Center.

4th grade Artist by Lillian A.

3rd grade Still Life by Derek P.

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Lice Lessons

Nits are tiny, teardrop-shaped lice eggs that are often yellowish or white. Nits are also what you call the shells that are left behind once the eggs hatch. Nits are attached to the hair shaft and often found around the nape of the neck or the ears. Nits can look similar to dandruff, but cannot be easily removed or brushed off.1

Nymphs, or baby lice, are small and grow to adult size in 1 to 2 weeks.1

Adult lice are the size of a sesame seed and appear tan to grayish-white.1

Head Lice 101What You Should Know About Head Lice

Overview

Head lice are a common community problem. An estimated 6 to 12 million infestations occur each year in the United States, most commonly among children ages 3 to 11 years old.1 Though a head lice infestation is often spotted in school, it is usually acquired through direct head-to-head contact elsewhere, such as at sleepovers or camp.2

Head lice are not dangerous, and they do not transmit disease.1 Additionally, despite what you might have heard, head lice often infest people with good hygiene and grooming habits.3,4 Your family, friends, or community may experience head lice. It’s important to know some basics, including how to recognize symptoms and what to do if faced with an infestation.

What are head lice?Head lice are tiny, wingless insects that live close to the human scalp. They feed on human blood.1 When checking for head lice, you may see several forms: the nit, the nymph, and the adult louse.

How are head lice spread?

• Head lice move by crawling and cannot jump or fly1

• Head lice are mostly spread by direct head-to-head contact—for example, during play at home or school, sleepovers, sports activities, or camp1

• It is possible, but not common, to spread head lice by contact with items that have been in contact with a person with head lice, such as clothing (for example, hats, scarves, or coats) or other personal items (such as combs, brushes, or towels)1

• Head lice transmission can occur at home, in the community, or —very infrequently—in school1,2

What are the signs and symptoms of infestation?Signs and symptoms of infestation include1:

• Tickling feeling on the scalp or in the hair

• Itching (caused by the bites of the louse)

• Irritability and difficulty sleeping (lice are more active in the dark)

• Sores on the head (caused by scratching, which can sometimes become infected)

Finding a live nymph or adult louse on the scalp or in the hair is an indication of an active infestation. They are most commonly found behind the ears and near the neckline at the back of the head.1

Fast Facts

• An estimated 6 to 12 million infestations occur each year among US children 3 to 11 years of age1

• Head lice do not discriminate, often infesting people with good hygiene.3,4 They spread mainly through head-to-head contact1

• If you or your child exhibits signs of an infestation, it is important to talk to your doctor to learn about treatment options

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Lice Lessons

Lice Lessons educational initiative is made possible through a collaboration with Arbor Pharmaceuticals, LLC.PP-NP-US-0256

References1. Centers for Disease Control and Prevention. Frequently asked questions (FAQs). http://www.cdc.gov/parasites/lice/head/gen_info/faqs.html. Accessed April 20, 2017. 2. Pontius DJ. Demystifying pediculosis: school nurses taking the lead. Pediatr Nurs. 2014;40(5):226-235. 3. Meinking T, Taplin D, Vicaria M. Infestations. In: Schachner LA, Hansen RC, eds. Pediatric Dermatology, 4th ed. Mosby Elsevier; 2011:1535-1583. 4. Centers for Disease Control and Prevention. Epidemiology & risk factors. http://www.cdc.gov/ parasites/lice/head/epi.html. Accessed April 20, 2017. 5. Centers for Disease Control and Prevention. Treatment. http://www.cdc.gov/parasites/lice/head/treatment.html. Accessed April 20, 2017. 6. Gellatly KJ, Krim S, Palenchar DJ, et al. Expansion of the knockdown resistance frequency map for human head lice (phthiraptera: pediculidae) in the United States using quantitative sequencing. J Med Entomol. 2016:1-7. 7. Centers for Disease Control and Prevention (CDC). Treatment frequently asked questions. http://www.cdc.gov/parasites/lice/ head/gen_info/faqs_treat.html. Accessed April 20, 2017.

Head Lice 101What You Should Know About Head Lice

What if my child gets head lice?If you suspect your child might have head lice, it’s important to talk to a school nurse, pediatrician, or family physician to get appropriate care. There are a number of available treatments, including new prescription treatment options that are safe and do not require nit combing. Other things to consider in selecting and starting treatment include:

• Follow treatment instructions. Using extra amounts or multiple applications of the same medicationis not recommended, unless directed by a healthcare professional5

• A 2016 study showed that 48 states now have lice that are genetically predisposed to resistanceto commonly used treatments6

• There is no scientific evidence that home remedies are effective treatments7

• Head lice do not infest the house. However, family bed linens and recently used clothes, hats,and towels should be washed in very hot water and dried on the high setting5

• Personal articles, such as combs, brushes, and hair clips, should be soaked in very hot water for5 to 10 minutes if they were exposed to someone with an active head lice infestation5

• All household members and other close contacts should be checked, and those with evidenceof an active infestation should also be treated at the same time5

Myths and facts about head lice

Myth: Only dirty people get head lice.Fact: Personal hygiene and household or school cleanliness are not factors for infestation. In fact, head lice often infest people with good hygiene and grooming habits.3,4

Myth: Head lice carry diseases.Fact: Head lice do not spread diseases.1

Myth: Head lice can be spread by sharing hair brushes, hats, clothes, and other personal items.Fact: It is uncommon to spread head lice by contact with clothing or other personal items, such as combs, brushes, or hair accessories, that have been in contact with a person with head lice.1

Myth: Head lice can jump or fly, and can live anywhere.Fact: Head lice cannot jump or fly, and only move by crawling. It is unlikely to find head lice living on objects like helmets or hats because they have feet that are specifically designed to grasp on to the hair shaft of humans. Additionally, a louse can only live for about a day off the head.1

Myth: You can use home remedies like mayonnaise to get rid of head lice.Fact: There is no scientific evidence that home remedies are effective treatments.7 Consult your healthcare provider to discuss appropriate treatment options, including prescription products.

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Interested in a non-traditional team sport for your Grade 3-12 child? Consider our youth cycling program! West Hartford ERRACErs Youth Cycling is affiliated with the CT Cycling Advancement Program (CCAP), a state-wide cycling league, and has MTB, road, and cyclocross programs available from March through December.

All practices are held in local parks and away from traffic. NO EXPERIENCE is required to be a part of our program. Bicycle and helmet required to participate (contact us if you need a bike). Group practices begin in early May.

We are now accepting new rider registrations for our summer road program. To register, please go to: https://www.bikereg.com/2019roadreg

Also, feel free to follow us via Facebook.com/erracers or email your questions to [email protected].

All licensed coaches are USA Cycling Certified, have completed background checks, and received SafeSport training.

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King Philip Middle School 7th Grader Avery Hersh invites 5th graders, middle and high school students and parents for an afternoon of ‘Finding Kind.’

The Kind Campaign is an internationally recognized organization that brings awareness and healing to the negative and lasting effects of bullying. (www.kindcampaign.com)

Stephen Boyle, M.Ed, CSC, LC, founder of 2•4•1 Sports, and his partner, Marc Lehman, LMFT, co-founders of Dorm Room Coaching & Counseling, will lead a discussion on how prevalent bullying is and how learning to be kind can prevent bullying and even save a life.

In addition, we will be showing a short and powerful documentary; “Finding Kind” which will be followed by an interactive discussion.

THE MANDELL JCC IS PROUD TO SPONSOR

Zachs Campus | 335 Bloomfield Ave.West Hartford, CT 06117

860-236-4571 | www.mandelljcc.org

Sunday, March 313:00-5:00pm

Free & open to the communityFor more information, contact,

Michelle Bonner, [email protected]

Stephen Boyle, M.Ed, CSC, LC • Founder/Director of 2•4•1 Sports• West Hartford Public Schools (WHPS) School

Counselor- Hall High School, King Philip and Bristow Middle School

• Partner - Dorm Room Coaching and Counseling• Founder and Advisory Board Chair - National

Association of Physical Literacy, NAPL-USA• Advisory Board Member CCSU Center of Excellence for

Social Emotional Learning (2017 - Present)

Marc Lehman, LMFT• BS Human Development and Family Relations• Masters Degree, Marriage & Family Therapy• Partner – Dorm Room Coaching and Counseling• Co-Developer & Owner, Family Resource and

Development Center, LLC (FRDC).• Member, American Association of Marriage and

Family Therapy

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PLAYIS FOR

ALL

WEST HARTFORD YMCA12 North Main Street West Hartford, CT 06107

860-521-5830WestHartfordYMCA.org

Adaptive So

ccer

Pro

gram

April 6– May 18, 2019Fee: $60

Saturdays: 10:00am–11:00amAges: 5–7

Saturdays: 11:00am–12:00pmAges: 8-10Financial Assistance Available

The program gives boys and girls with physical or intellectual disabilities the opportunity to develop new skills, and build self-confidence, all while making new friends and participating in friendly soccer games.

To register for the program visit our website at WestHartfordYMCA.org.

To become a volunteer, send an email to [email protected] register atghymca.volunteermatters.org

19-03-007

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KidzWhiz Math Camp

Does your child love math challenges? Looking for a way to keep

his or her creative thinking flowing over the summer? KidzWhiz

Math Camp focuses on the core topics from grade level curriculum

with an extensive range of fun & exciting math activities designed to

challenge students entering grades 1-3. An academic learning

opportunity, committed to enriching their love of mathematics.

Camp classes are offered in an engaging group setting with hands-on

mathematic activities. Taught by West Hartford elementary school teachers

who have several years of experience teaching a math enrichment program.

Monday – Friday

8:30-11:30 am

Location: Smith School

Fee: $175/session

Sessions: June 24 – 28, 2019 Program #: 411542A

July 15 – 19, 2019 Program #: 411542B

Register On-Line at www.westhartfordct.gov/leisureservices

1) Click on the Link: Online Registration 2) Enter Your User ID and Password (for help see forgot password tab) 3) Type Program # in Activity Search Box 4) Click on Shopping Cart to Enroll 5) Select Family Member 6) Proceed With Payment

Town of West Hartford – Department of Leisure and Social Services

860-561-7510

Interested parties must register with Leisure Services before the start of class. Safety and Emergency Contact Information Required.

(Form available during online registration process.)

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APRIL 2019

VACATION FUN CAMPS

Register Online or Complete Registration and Safety Form and Send to Appropriate Facility:

(See Below for Online Registration Information and Registration Form) 1. Customer Service, Town Hall, 50 South Main Street, W.H. 06107 - Phone 860-561-7510, FAX 860-561-7519 2. Elmwood Community Center, 1106 New Britain Avenue, W.H. 06110 - Phone 860-561-8160, FAX 860-561-8161 3. Veterans Skating Rink, 56 Buena Vista Road, W.H. 06107 - Phone 860-561-8290, FAX 860-561-8291 4. Westmoor Park, 119 Flagg Road, W.H. 06117 - Phone 860-561-8260, FAX 860-236-3815

For weather cancellations, please call the facility listed above.

BASEBALL TRAINING CAMP

Age 6 - 12 Your child will be provided with the fundamentals, rules and other aspects of baseball. Proper techniques in throwing, hitting, base running and fielding will be taught. Players will engage in simulated baseball situations with one-on-one instruction from highly skilled instructors. Players will showcase their skills in competition game play at the conclusion of the camp. Appropriate sportsmanship will be modeled and required from all participants. It is suggested that your child come prepared with a glove, cleats and a snack. Please dress according to the weather (no shorts). In the event of inclement weather, camp will be held at a different location to be determined. The instructor will notify participants by 8:00 am. Instructors: David Volpe & Staff 414538A Mon-Thu 9:00A - 12:00P 4/8 - 4/11 R$118/NR$130 LOCATION: CONARD HIGH SCHOOL

Safety & Emergency Information Required on Registration Form Register On-line, Fax or Mail to Town Hall, Customer Service Desk

BON APPETIT I: AN INTRODUCTORY JOURNEY THROUGH FRANCE

Age 10 - 12 Your child will love joining Madame Machelle for a fun week of cooking, eating and speaking French while learning about the cuisine of France. Students will be introduced to elementary French language as it applies to cooking and eating. Each day we will explore a different region of the country and prepare a local specialty, which we will serve and eat in the French “café” style. The class will include hands-on participation and role-playing in French. Please be aware that the cooking projects will NOT be allergy-sensitive. A materials fee of $25.00 will be payable to the instructor at the first class and will cover lesson book, apron and food. Instructor: Machelle Rosenlieb 364257A Mon-Fri 1 :30P - 3 :30P 4/8 - 4/12 R$100/NR$110 LOCATION: ELMWOOD COMMUNITY CENTER

Register On-line, Fax or Mail to Elmwood Community Center

APRIL ADVENTURE CAMP (Full Day)

Age 5 – 12

Need care when school is out for Spring Break? ECC is the place! Your child will participate in age appropriate activities like arts and crafts, gym time, games, free play or on-site special events, including a visit from the animals of the Children’s Museum where campers will learn wildlife adaptation and habitat. Camp will also include daily outside play to add to your camper’s experience (weather permitting). This camp is the perfect way to spend an exciting April vacation at ECC! Instructors: ECC Staff 364101A Mon-Fri 8:30A - 4:30P 4/8 - 4/12 R$185/NR$195 LOCATION: ELMWOOD COMMUNITY CENTER

Safety & Emergency Information Required on Registration Form Register On-line, Fax or Mail to Elmwood Community Center

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TENNIS FPTA VACATION CAMP

Age 8 - 14

This program offers campers a combined emphasis on instruction and modified matchplay. Campers should come prepared with a racquet, hat, water, snacks and sunscreen. In case of rain, camp will be moved indoors. Instructors: Fern Park Tennis Association 414539A Mon-Fri 1 :00P - 4 :00P 4/8 - 4/12 R$181/NR$194 LOCATION: HALL HIGH SCHOOL

Safety & Emergency Information Required on Registration Form Register On-line, Fax or Mail to Town Hall, Customer Service Desk

GOLF BEGINNER ACADEMY

Age 9-14 This program is for golfers at the beginner level. Golf instruction as well as golf rules and etiquette will be included in the camp. In case of heavy rain, or any questions, please call Rockledge Golf Club at 860-521-6284. Instructors: Rockledge Staff 414535A Tue-Thu 9 :30A - 11 :30A 4/9 - 4/11 R$84/NR$94 LOCATION: ROCKLEDGE GOLF CLUB

Register On-line, Fax or Mail to Town Hall, Customer Service Desk

MINE, CRAFT, BUILD ADVENTURE GAME WITH LEGO® MATERIALS

Age 5-6 Bring Minecraft to life using LEGO® materials! Resourcefulness, creativity and cooperation come together in this unique building adventure game where kids will roll the dice to mine for resources, then use those resources to build special items to help in the adventures! Options include building a Zoo, creating a Medieval Castle and designing a Tree House Village. This experience is an original game designed by Play-Well instructors inspired by the popular game, Minecraft. Students will have a blast, even without any pior experience with Minecraft or LEGO® materials. Instructors: Play-Well TEKnologies Staff 364254A Mon-Fri 9 :00A - 12 :00P 4/8 - 4/12 R$130/NR$140 LOCATION: ELMWOOD COMMUNITY CENTER

Safety & Emergency Information Required on Registration Form Register On-line, Fax or Mail to Elmwood Community Center

MINE, CRAFT, BUILD SURVIVAL GAME WITH LEGO® MATERIALS

Age 7 - 12 Minecraft comes to life using LEGO® materials! Resourcefulness, creativity and cooperation come together in this unique building adventure game where kids will roll the dice to mine for resources, craft tools and watch out for Creepers! This ultimate Play-Well Minecraft experience using LEGO® materials is an original game designed by Play-Well instructors, using gameplay elements and characters inspired by the popular Minecraft video game. Students will have a blast, even without any prior experience with Minecraft or LEGO® materials. Instructors: Play-Well TEKnologies Staff 364255A Mon-Fri 1 :00P - 4 :00P 4/8 - 4/12 R$130/NR$140 LOCATION: ELMWOOD COMMUNITY CENTER

Safety & Emergency Information Required on Registration Form Register On-line, Fax or Mail to Elmwood Community Center

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WESTMOOR PARK: APRIL ADVENTURES

Age 6 - 12 This adventure is designed for students in grades 1-6, ages 6-12. They’ll have lots of fun at the park as they explore the mysteries of the natural world through hikes, experiments, crafts and other outdoor activities designed especially for the spring. Sign up for Lunch Bunch (see below) if you are registered for the morning and afternoon. Instructors: Westmoor Park Staff 524407A Mon-Fri 9:00A - 12:00P 4/8 - 4/12 R$159/NR$169 524407B Mon-Fri 1:00P - 4:00P 4/8 - 4/12 R$159/NR$169 LOCATION: WESTMOOR PARK

Safety & Emergency Information Required on Registration Form Register On-line, by Fax or Mail to Westmoor Park

WESTMOOR PARK: PRESCHOOL ADVENTURES

Age 4 - 5 This adventure is designed for children in preschool and kindergarten. They will explore the mysteries of the natural world through hikes, stories, game and crafts. Children will use their five senses to discover the secrets of nature in the great outdoors. Children must be toilet trained by the first day of camp. Instructors: Westmoor Park Staff 524207A Mon-Fri 9:00A - 12:00P 4/8 - 4/12 R$159/NR$169 LOCATION: WESTMOOR PARK

Safety & Emergency Information Required on Registration Form Register On-line, Fax or Mail to Westmoor Park

WESTMOOR PARK: APRIL ADVENTURES LUNCH BUNCH

Age 6 - 12 Lunch Bunch is supervised time for children who sign up for the morning and afternoon sessions of April Adventures. Please bring a labeled

lunch and drink. Instructors: Westmoor Park Staff 524999A Mon-Fri 12:00P - 1:00P 4/8 - 4/12 R$40/NR$45 LOCATION: WESTMOOR PARK

Safety & Emergency Information Required on Registration Form Register On-line, Fax or Mail to Westmoor Park

Register On-Line at www.westhartfordct.gov/leisureservices

1) Click on the Link: Online Registration 2) Enter Your User ID and Password (for help see forgot password tab) 3) Type Program # in Activity Search Box 4) Click on Shopping Cart to Enroll 5) Select Family Member 6) Proceed With Payment

VACATION SKATING CAMP (Full Day)

Age 6 - 11 This popular and exciting camp combines both on and off ice activities. Daily activities include supervised skating time and off-ice activities including games, crafts, movies and more! Fees include skate rental if needed. Instructors: Veterans Rink Staff 424310 A Mon-Fri 8:30A - 4:30P 4/8 - 4/12 R$220/NR$230 LOCATION: VETERANS MEMORIAL RINK

Safety & Emergency Information Required on Registration Form Register On-line, Fax or Mail to Veterans Memorial Rink

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REGISTRATION FORM – Please complete separate form for each participant

PARTICIPANT’S LAST NAME______________________________________First Name___________________________

Birth Date Age _____ Male ____ Female ____ Entering Grade _______ (if applicable)

SPECIAL CONCERNS: List any special needs or health related issues or concerns of participant:__________________

___________________________________________________________________________________________________________

PROGRAM # TITLE DATES TIME FEE

PAYMENT TYPE: Cash (in person only) Check # (payable to

“Town of West Hartford”)

TOTAL

___VISA ___Master Card _______ ____________________ ____Expiration Date: _____________________ Month Year

Household Information (Please print)

Your Name or Parent/Guardian: Last Name __________ ________ First Name _______________________

Street ___________________ Town Zip

Home Phone # _________ Work Phone # _________ Cell Phone #

EMAIL:________________________________________________________________________________________________________________

Emergency Contact for Participant _______ Relationship ____________

Home Phone # __________ Work Phone # _________ Cell Phone # _______________

I realize that as with any physical activity there is a possible risk of accidental injury to me/my child while participating in this West Hartford Leisure Services Program. I agree to assume the risk of any injury which I/my child might suffer while involved in the West Hartford Leisure Services Program and will not hold the Town of West Hartford or its instructors liable for any injuries which I/my child may suffer while participating in this West Hartford Leisure Services Program.

Signature of Parent or Guardian: __________ Date _________

SAFETY AND EMERGENCY INFORMATION

This section MUST BE COMPLETED if you are registering a CHILD for a program that runs 3 HOURS OR MORE A DAY.

Has participant been prescribed an Epi-pen? Yes_____(if yes, an Epi-pen form will be sent to you) No______

Please list and describe your child’s known allergies, known illnesses, physical limitations, special needs etc. Please list and describe:

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

List Medications _______________________________

Family Doctor’s Name _________ Doctor’s Phone Number _______________

Please read below and if you understand and agree to each statement write your initials in the space next to the paragraph to signify your understanding and agreement.

In the event my child needs emergency hospital or medical care while participating in this West Hartford Leisure Services Program and there is no time for me to be contacted and/or I cannot be reached, my hospital preference is:

Hospital Name ___________________________ ___ However, if circumstances are such that it is deemed necessary to admit elsewhere, permission is hereby granted. If my child needs emergency medical care while in this West Hartford Leisure Services Program, I hereby give permission for the

hospital to give such emergency treatment as is considered necessary or desirable by medical judgment, including administration of anesthesia. If my child needs to be transported by an ambulance, I give my permission for such transportation and I agree to assume all expenses

incurred by said transportation. I agree to assume all medical expenses incurred by my child while participating in this West Hartford Leisure Services Program.