Credit/Debit Card Charge - Summer Camp Programs offered by

SUMMER
Conejo Valley Unified School District
Child Care Program
Sign-Out Authorization
Child’s Name:______________________ School:_____________________
Child’s Name:______________________
This form must be filled out in addition to the Emergency Authorization. Children will
only be released to people who are listed on this form. Please list names of all
persons who are authorized to sign out your child (including yourself, spouse,
siblings, friends, etc.):
1. Name:____________________________ Relationship:_____________________
2. Name:____________________________ Relationship:_____________________
3. Name:____________________________ Relationship:_____________________
List two local persons who could be called to pick up your child in your absence
1. Name:____________________________ Relationship: _____________________
Work Phone:_______________________ Home Phone:_____________________
Cell Phone: _____________________
2. Name:____________________________ Relationship: _____________________
Work Phone:_______________________ Home Phone:_____________________
Cell Phone: _____________________
_______________________________________
Parent/Guardian Signature
CVUSD Child Care 2801 Atlas Avenue Thousand Oaks CA 91360 Phone 805‐492‐3567 Fax 805‐492‐2302 Email [email protected] Tax ID # 95‐286‐8899 Credit/Debit Card Authorization I hereby authorize my financial institution to make periodic payments on my behalf from the credit account listed below and transfer it to Conejo Valley USD Child Care. 2016 SUMMER CAMP – SESSION (Earths, Lang Ranch, Sycamore) CHILD NAME _______________________________Gr_____ SUMMER CAMP LOCATION __________________________ USE THIS EFT FORM FOR Credit/Debit Card Payment
EARTHS LANG RANCH SYCAMORE □ Credit/Debit Card Charge
_____ Visa _____ MasterCard
_______ - _______ - _______ - _______
(Credit/Debit Card Number)
_______________Exp(00/00) _________CVV
□ Processing Fee $50 per session, per child $ ______
Enrolling for: Session #1 – 6/13 #2 – 7/5 #3 – 7/25 I agree to pay Summer Camp tuition as follows: □ Session #1 ‐ May 16
□ Session #2 ‐ June 20
□ Session #3 – July 8 $ _________ SESSION CAMPS ONLY $ _________ $ _________
or □ All sessions, in full (no discount) $ _________
TOTAL ON CARD (incl proc fees)
$ _________ I understand that I assume full responsibility of my payments and I will notify you if at any time I decide to make any changes, discontinue this service, or change or close my credit/debit card account. Any updates in credit card information must be received by the above tuition due dates to maintain summer camp enrollment. Name ____________________________________________ (as printed on credit card) Address ___________________________________________ City _________________ State ______Zip ____________ Signature__________________________________________ Phone _______________ cell wk hm Date ___________ Staff Init ______ CVUSD Child Care 2801 Atlas Avenue Thousand Oaks CA 91360 Phone 805‐492‐3567 Fax 805‐492‐2302 Email [email protected] Tax ID # 95‐286‐8899 Credit/Debit Card Authorization I hereby authorize my financial institution to make periodic payments on my behalf from the credit/debit account listed below and transfer it to Conejo Valley USD Child Care. 2016 MADRONA WEEKLY SUMMER CAMP CHILD NAME _______________________________Gr_____ Credit Card Payment
□ Credit/Debit Card Charge
_____ Visa _____ MasterCard
_______ - _______ - _______ - _______
(Credit/Debit Card Number)
_______________Exp(00/00) _________CVV
□ Processing Fee $20 per week, per child $ ______
#1 – 6/13 #2 – 6/20 #3 – 6/27 #4 – 7/5 #5 – 7/11 #6 – 7/18 #7 – 7/25 #8 – 8/1 #9 – 8/8 I agree to pay Summer Camp tuition as follows: □ Weeks 1‐3 May 16
□ Weeks 4‐6 June 20
□ Weeks 7‐9 July 8
$ _________ $ _________ $ _________
or □ All weeks, in full (no discount) $ _________
TOTAL ON CARD (incl proc fees)
$ _________ I understand that I assume full responsibility of my payments and I will notify you if at any time I decide to make any changes, discontinue this service, or change or close my credit/debit card account. Any updates in credit card information must be received by the above tuition due dates to maintain summer camp enrollment. Name ____________________________________________ (as printed on credit card) Address ___________________________________________ City _________________ State ______Zip ____________ Signature__________________________________________ Phone _______________ cell wk hm Date ___________ Staff Init ______ USE THIS EFT FORM FOR MADRONA WEEK‐TO‐WEEK CAMP ONLY CVUSD Summer Camp Swimming Information
CHILD’S NAME:_________________________________ AGE:___________
Has your child taken swim lessons?
YES
NO
If yes, how many years? ________________
How would you classify your child’s swim ability?
*(See below for additional information)
Non-swimmer
Adequate swimmer
Confident swimmer
*Non-swimmer cannot swim crawl stroke (freestyle) any yardage. Has
little or no water experience and can not put face in the water.
*Adequate swimmer has basic skills, but is still not able to swim great
lengths. Is not comfortable in deep water and working on the ability to
float and be an independent swimmer.
*Confident swimmer has had at least two to three solid summers of
consistent and confident swimming skills. Is comfortable putting face in
the water and able to float. Can be in portions of the pool that they are
unable reach the bottom or hold on to the side.
Additional information regarding your child’s swim ability:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Swim tests may be given to campers to confirm swimming ability. There
will be no test for “non-swimmers” and those campers must remain in
the wading pool. In order to swim in the larger pools, campers must be
able to:
 Swim 15 yards
 Swim 25 yards (to use the diving boards)
_______________________________________________________ _______________
PARENT SIGNATURE
DATE
CVUSD Child Care Accommodations
As a District program of Conejo Valley Unified School District, the Child Care
program is committed to providing equal access for services and activities to
students who are classified as disabled under Section 504 of the federal
Rehabilitation Act of 1973. The CVUSD Child Care Program strives to meet the
individual needs of students with disabilities as adequately as the needs of
nondisabled students without cost to the student or his/her parent/guardian,
except when a fee is imposed on nondisabled students. (CVUSD Administrative
Regulation 6164.6)
Please complete the following section if your child has specific medical needs.
Your assistance in completing this form will allow us to plan a safe and
successful program for your son/daughter.
Special Accommodations Protocol
Student’s Name: ____________________________________
Child Care Center: ____________________________________
Please advise us if your child is a diabetic, has insect or food allergies, asthma or
other special needs that will require staff supervision. Please explain below the
nature of your child’s special needs and staff will contact you to discuss any
specific issue(s) and or procedure(s) necessary for a safe and dynamic Child
Care experience.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Parent Signature: _________________________________________________
Phone #: ________________________________________________________
Using Technology in School
Student Acceptable Use Policy and BYOD
Student Responsible Use Agreement
After reviewing the presented guidelines and expectations available at www.conejousd.org or in print by
request, students and parents acknowledge the following by signing this policy. As a Conejo Valley
Unified School District student, I understand that:
1. MY USE OF THE SCHOOL NETWORK AND EMAIL IS A PRIVILEGE, NOT A RIGHT.
2. MY SCHOOL AND DISTRICT’S NETWORK AND EMAIL ACCOUNTS ARE OWNED BY THE
CVUSD AND ARE NOT PRIVATE. CVUSD HAS THE RIGHT TO ACCESS MY INFORMATION
AT ANY TIME.
3. CVUSD ADMINISTRATORS, LOCAL TEACHERS, AND LAW ENFORCEMENT WILL DEEM
WHAT CONDUCT IS INAPPROPRIATE USE IF SUCH CONDUCT IS NOT SPECIFIED IN THIS
AGREEMENT.
4. I UNDERSTAND THAT I AM TO NOTIFY AN ADULT IMMEDIATELY IF I ENCOUNTER
MATERIAL THAT VIOLATES APPROPRIATE USE.
5. I AM RESPONSIBLE FOR MY COMPUTER ACCOUNT AND EMAIL ACCOUNT.
6. I WILL NOT ALLOW OTHERS TO USE MY ACCOUNT NAME AND PASSWORD, OR TRY TO
USE THAT OF OTHERS.
7. I WILL USE TECHNOLOGY IN A MANNER THAT COMPLIES WITH LAWS OF THE UNITED
STATES AND THE STATE OF CALIFORNIA, INCLUDING COPYRIGHT LAWS.
8. I AM RESPONSIBLE FOR MY LANGUAGE AND CONDUCT.
9. I AM RESPONSIBLE FOR PROTECTING S C H O O L P R O P E R T Y , I N C L U D I N G THE
SECURITY OF THE CVUSD’s NETWORK.
10. I AM RESPONSIBLE FOR FOLLOWING SCHOOL RULES AND THE GUIDELINES WITHIN
THIS DOCUMENT WHENEVER I PUBLISH ANYTHING ONLINE.
Student:
I understand and will obey the rules of the CVUSD Acceptable Use Policy. I will use CVUSD technology
resources productively and responsibly for school-related purposes. I will not use any technology resource
in such a way that would be disruptive or cause harm to other users. I understand that consequences of
my actions could include possible loss of computer privileges and/or school disciplinary action as stated in
the CVUSD Discipline Handbook and/or prosecution under state and federal law.
Student Signature (above Grade 2)
Date
Parent or Guardian:
As the parent or guardian, I have read the CVUSD Acceptable Use Policy and I have discussed it with my
child. I understand that computer access is provided for educational purposes in keeping with the
academic goals of CVUSD, and that student use for any other purpose is inappropriate. I recognize it is
impossible for CVUSD to restrict access to all inappropriate materials, and I will not hold the school or
District responsible for materials acquired on the school network. I understand that children’s computer
activities at home should be supervised as they can affect the academic environment at school. I hereby
give permission for my child to use technology resources at Conejo Valley Unified School District.
Parent or Guardian's Name (please print)
Parent or Guardian's Signature
AUP – CVUSD
Form 90-00027 Revised 06/15
Date
Uso de Tecnología en la Escuela
Política de Uso Aceptable del Estudiante y
Traiga su Propio Aparato
Acuerdo de Uso Responsable del Estudiante
Luego de revisar las reglas generales y expectativas presentadas, disponibles en www.conejousd.org o
impresas bajo pedido, los estudiantes y los padres aceptan lo siguiente mediante la firma de este
documento. Como estudiante del Distrito Escolar Unificado del Valle Conejo, entiendo que:
1. MI USO DE LA RED ESCOLAR Y CORREO ELECTRÓNICO ES UN PRIVILEGIO, NO UN
DERECHO.
2. MI ESCUELA, LA RED DEL DISTRITO Y MIS CUENTAS DE CORREO ELECTRÓNICO SON
PROPIEDAD DE CVUSD Y NO SON PRIVADAS. CVUSD TIENE DERECHO A ACCEDER A MI
INFORMACIÓN EN CUALQUIER MOMENTO.
3. LOS ADMINISTRADORES DE CVUSD, MAESTROS LOCALES Y LA POLICÍA JUZGARÁN QUÉ
CONDUCTA ES UN USO INAPROPIADO, SI TAL CONDUCTA NO SE ESPECIFICA EN ESTE
ACUERDO.
4. ENTIENDO QUE DEBO DE NOTIFICAR UN ADULTO INMEDIATAMENTE, SI ENCUENTRO
MATERIAL QUE VIOLE EL USO APROPIADO.
5. SOY RESPONSABLE DE LA CUENTA DE MI COMPUTADORA Y CUENTA DE CORREO
ELECTRÓNICO.
6. NO VOY A PERMITIR QUE OTROS UTILICEN MI NOMBRE DE USUARIO Y CONTRASEÑA, O
TRATAR DE UTILIZAR LA DE LOS DEMÁS.
7. VOY A UTILIZAR TECNOLOGÍA DE MANERA QUE CUMPLA CON LAS LEYES DE LOS ESTADOS
UNIDOS Y EL ESTADO DE CALIFORNIA, INCLUYENDO LAS LEYES DE DERECHO DE AUTOR.
8. SOY RESPONSABLE DE MI VOCABULARIO Y CONDUCTA.
9. SOY RESPONSABLE DE LA PROTECCIÓN DE LA PROPIEDAD DE LA ESCUELA, INCLUYENDO
LA SEGURIDAD DE LA RED DE CVUSD.
10. SOY RESPONSABLE DE SEGUIR LAS NORMAS ESCOLARES Y LAS REGLAS GENERALES DE
ESTE DOCUMENTO CADA VEZ QUE YO PUBLIQUE CUALQUIER COSA EN LÍNEA.
Estudiante:
Entiendo y obedeceré las reglas generales de la Política de Uso Aceptable de CVUSD. Voy a utilizar los
recursos tecnológicos de CVUSD de manera productiva y responsablemente para fines relacionados con
la escuela. No utilizaré ningún recurso tecnológico, de tal manera que sea perjudicial o cause daño a
otros usuarios. Entiendo que las consecuencias de mis acciones podrían incluir una posible pérdida de
privilegios de la computadora y/o acción escolar disciplinaria como se indica en el Manual de Disciplina de
CVUSD y/o procesamiento judicial en virtud de la ley estatal y federal.
Firma del estudiante (mayores de 2do Grado)
Fecha
Padre o Tutor:
Como padre o tutor, he leído la Política de Uso Aceptable CVUSD y la he discutido con mi hijo. Entiendo
que se proporciona acceso a una computadora para propósitos educativos de acuerdo con las metas
académicas de CVUSD y que el uso por parte del estudiante para cualquier otro propósito es inadecuado.
Reconozco que es imposible para el Distrito restringir el acceso a todos los materiales inapropiados y no
responsabilizaré a la escuela o al Distrito por materiales adquiridos en la red escolar. Entiendo que las
actividades informáticas de los niños en el hogar deben ser supervisadas, ya que pueden afectar el
ambiente académico en la escuela. Doy permiso para que mi hijo use los recursos tecnológicos en el
Distrito Escolar Unificado del Valle Conejo.
Nombre del Padre o Tutor (letra de imprenta)
Firma del Padre o Tutor Firma
AUP – CVUSD
Form 90-00027 Revised 06/15
Fecha
OPT-OUT FOR
RELEASE OF INFORMATION
This form is NOT required if you are permitting
release of your child’s information.
Student’s Name:
Residence
Address:
Grade Level:
Date of Birth (mo/dy/yr):
City:
Zip:
Home Phone:
Cell/Work Phone:
School Name:
School Year:
The Family Educational Rights and privacy Act (FERPA) and Education Code 49073 permits CVUSD to disclose
appropriately designated “directory information” without written consent, unless you have advised the District that
you do not want your student’s directory information disclosed. Directory information may include names, addresses,
telephone numbers, and information that is generally not considered harmful or an invasion of privacy.
At times, a “photographic image” of a student may be published or televised by a school, school district, or public
media. Photographic images include pictures, digital images, website images, videotapes, DVD’s, televised images,
etc.
Directory information and/or photographic images may occasionally be used in various forms of mass communication
referred to as “media” such as a school directory, yearbook, website, school or public newspaper or online news,
school or public televised media, etc.
Below please initial only those that apply:
_____ By initialing here, I request that my child’s directory information and/or photographic image NOT be released
by school personnel for INTERNAL USE in media of my school, the district, or school-related organizations
(such as Parent Teacher Association (PTA), Parent Faculty Association (PFA), or Parent Teacher Student
Association (PTSA)). This would include exclusion from class photos, school yearbook, and the
school’s website.
_____ By initialing here, I request that my child’s directory information and/or photographic image NOT be released
by school personnel to any form of EXTERNAL PUBLIC MEDIA (such as newspapers, television, etc). This
would include activities such as student recognitions, honors, topics of interest, etc.
If you did not initial any of the above, this form does NOT need to be submitted to the school.
If you do not return this form to the office at your school,
CVUSD will assume permission to release this information.
Print Parent/Guardian Name
CVUSD 94-00077 Pk 50 (Rev 7-2015)
Signature of Parent/Guardian
Date
OPTAR POR NO
CEDER INFORMACIÓN
Esta forma NO se requiere si Ud. está
permitiendo ceder información de su niño.
Nombre del Estudiante:
Grado:
Residencia:
Fecha Nacimiento:
Ciudad:
Código Postal:
Teléfono Casa:
Teléfono Cel/Trabajo:
Nombre Escuela:
Ano Escolar:
Los Derechos Educacionales de la Familia y el Acto de Privacidad (FERPA) y Código Educacional 49073, permite a
CVUSD ceder “información del directorio” apropiadamente designada sin consentimiento escrito, a no ser que Ud.
haya hecho saber al Distrito, que Ud. no quiere ceder información del directorio de su estudiante. La información del
directorio puede incluir nombres, direcciones, números telefónicos e información que generalmente no es considerada
dañina o una invasión a la privacidad.
A veces una “imagen fotográfica” de un estudiante, puede ser publicada o televisada por la escuela, distrito escolar
o medio público. Imágenes fotográficas incluyen fotos, imágenes digitales, imágenes en la red, cintas de video, DVD’s,
imágenes televisadas, etc.
Información del directorio o anuario y/o imágenes fotográficas, ocasionalmente pueden ser usadas en variadas formas
de comunicación masiva, a las cuales nos referimos como “medio” como un directorio escolar, anuario, sitio de la red,
periódico escolar o público o noticias en línea, medio de televisión escolar o pública, etc.
Por favor, iniciales abajo solo en lo que se aplique:
_____ Inicializando aquí, solicito que la información del directorio de mi niño y/o imagen fotográfica NO sea publicada
por el personal escolar para USO INTERNO en medios de mi escuela, el distrito u organizaciones relacionadas
a la escuela (como Asociación de Padres y Maestros (PTA), Asociación de Padres y Facultad (PFA), o
Asociación de Padres, Maestros y Estudiantes (PTSA)). Esto incluye exclusión de fotografías de la clase,
anuario escolar, y el sitio web de la escuela.
_____ Inicializando aquí, solicito que la información de directorio de mi niño y/o imagen fotográfica NO sea publicada
por el personal escolar a cualquier medio de COMUNICACIÓN PÚBLICA EXTERNA (como periódicos,
televisión, etc). Esto incluiría actividades como reconocimientos estudiantiles, honores, temas de
interés, etc.
Si Ud. no puso sus iniciales a ninguna de las áreas de arriba, ésta forma NO necesita ser entregada a la escuela
Si Ud. no devuelve esta forma a la oficina de la escuela,
CVUSD asumirá permiso para ceder esta información.
Imprimir Nombre Padre/Tutor
CVUSD 94-00077 Pk 50 (Rev 7/2015)
Firma Padre/Tutor
Fecha