PSA Test

Please select one*

Plantersville Summer Academy
Plantersville Enrichment Academy, After-School
Summer Bridge Program (PES Students, Only)

Student's Name*

Grade (for the 2022-23 school term)*

Date of Birth*

School attended 2021-22 school year*

IEP Submitted*

Yes
No

T-Shirt Size*

One T-shirt provided; additional T-shirt available for $7.00 and must be prepaid before ordering.

List number of extra shirts

Parent/Guardian

Name*

Address*

Cell Phone*

Home Phone

Email*

Emergency Contact 1

Name*

Primary Phone*

Secondary Phone

Emergency Contact 2

Name*

Primary Phone*

Secondary Phone

Physician & Medical Information

Physician's Name*

Primary Phone*

Secondary Phone

Preferred Hospital*

Insurance / Health Coverage (Company)*

List current medications*

List medication allergies*

List food allergies*

List chronic health concerns*

Consent and Release

General Parental/Guardian Consent: As Parent/Guardian I/WE hereby affirm that the student is in good health and suffers from no illness, disability or condition that requires the taking of medication on a regular basis unless that condition is disclosed and approved by program staff. Furthermore, I have no knowledge of any reason the student cannot participate in vigorous physical activity.

I/We expressively agree to be responsible for any medical bills incurred in the treatment of any illness or accident. In the event of any such accident or injury, I /We hereby consent to allowing any of the program supervisors to procure any medical treatment deemed advisable on behalf of your child or ward without prior consent.

I/WE understand that, as a condition of admittance as program participant, I/We, on behalf of all parents and guardians, and on behalf of the student, hereby release The Village Group and its affiliated programs, and all other employees or agents of The Village Group from any and all liability from injury or illness, mental or physical, suffered by the program participant during or related to the program, unless caused by a willful act or gross negligence by the person or entity against whom the claim is made.

Medical Release: As Parent/Guardian I/We hereby give permission The Village Group staff/volunteer to proceed with emergency treatment in the event of accidental injury or illness provided of the immediate family or listed emergency contacts cannot be reached.

PHOTO RELEASE:I further authorize The Village Group, its affiliates, its successors or assigns, the right to take photographs for marketing and other purposes, as it deems appropriate.

Student's Name*

Parent/Guardian (Print)*

Parent/Guardian (Signature)*

Today's Date*

Student Record Release

The purpose of the Federal Educational Rights and Privacy Act of 1974 is to protect the privacy of information concerning individual students by placing restrictions on the disclosure of information contained in a student’s education records. By signing below, I hereby authorize Georgetown County School District to release my education records (individuals age 18 and older) or the education records of my child, as described below:

Student's Name*

Date of Birth*

Please select one:*

I, as an eligible student or parent/guardian authorize Georgetown County School District to release my/my child’s entire educational record.
I, as an eligible student or parent/guardian authorize Georgetown County School District to release only the portions of my/my child’s educational record as listed below:

Select all that apply:*

Health and Immunization Records (including hearing and vision screenings)
Report Cards
Testing Information
Discipline Records
Special Education Records
Other

Other: Please specify*

Individual(s)/Organization(s)/Agency(ies) to Whom Records May Be Disclosed: The Village Group

Purpose of Disclosure: To obtain, thru power school and local school officials, student level participation (attendance), testing information, and report cards.

Signature of Parent/Guardian or Eligible Student*

Today's Date*

I am the (check one):*

Online Payment

Non-refundable Registration fee*

Additional T-shirts

One T-shirt provided; additional T-shirt available for $7.00 and must be prepaid before ordering. List the number of extra shirts (Final order date May 4th )

Price: $7.00

Tuition Fee (June 6 – July 21, 2022)

You may choose to pay the Tuition Fee at this time. If you prefer to pay for the Tuition Fee at a later date please use the separate Tuition form located here: https://thevillagegroup.org/after-school-programs/plantersville-summer-academy/plantersville-summer-academy-tuition-fee/

Donation

3% credit/debit card service charge

Price: $0.00

Total

$0.00

Payment Method*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Name

This field is for validation purposes and should be left unchanged.

PSA Registration - The Village Group

Parent/Guardian

Emergency Contact 1

Emergency Contact 2

Physician & Medical Information

Consent and Release

Student Record Release

Online Payment

PSA Tuition Fee - The Village Group

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