Summer Youth College July 13-16, 2015 Plan your summer fun now! Join our talented instructors for four days of classes that challenge your mind and stretch your imagination! This academic summer camp is for students entering the 1st through 6th grades in the Fall. WEEKLY SCHEDULE Parent Orientation Monday only 8:00 am – 8:30 am Classes Monday – Thursday 8:30 am – 12:00 pm General Information: Summer Youth College will be held Monday through Thursday, July 13-16, 2015, on the MCC North Campus in the Brown Badgett Center(BBC). All students will attend three classes that meet one hour each day from 8:30 am to 12 pm. Students will be grouped into classes customized for their grade level (Grades 1 & 2; Grades 3 & 4; and Grades 5 & 6). Family and friends are encouraged to come to a 30-minute Orientation on Monday at 8:00 am held at the BBC so that they can be introduced to their children’s instructors and hear pertinent information about the week’s activities. This format will allow students to select three action-packed classes for one low fee of $88. Daily snacks, classroom supplies and 2015 SYC T-Shirts are included in the cost.
Register Early! Enrollment is limited to the first 20 paid registrants in each class.
Class Selection Choose one class from each pair of classes listed below. You will attend the same three classes each day. Class enrollment is limited. If a class you choose is full or does not make, you will be placed in the other class in the pair.
SUMMER YOUTH COLLEGE 2015 CLASSES
Choice One Grossology with Bethany Crouch
OR
Do you like gross, sticky, slimy,exploding, and tasty science experiments? In Grossology we will have 4 days packed with science fun that just may blow you your socks off or simply make you hungry for more! *SC
Koolinary Kreations with Amanda Crabtree Test your "KOOL-inary" skills! Use your math and reading skills to create edible fun. Learn how to create snacks without an oven! *LA *MA *SC
Choice Two Totally Tribal with Sharon & Steve Mathias
OR
What do Minnie Mouse, Batman, and The Hulk have in common? They're all tasty as cookies! Learn how to decorate cookies with your favorite cartoon characters: Mickey, Minnie, TMNT, Captain America, The Hulk, Spiderman, Batman, and Superman. Which will be your favorite to decorate? *AR
Do YOU know the Native Americans? Join us for a day in the life of the Native Americansexperience food, clothing, and family fun just like the Indians. Don't miss out on our totally "teepeed" display! *AR *DA *LA *SS
Choice Three Crazy for Coal with James McClain
Cartoon Classics with Glenn Riggs
OR
Can you dig it? Learn the facts about coal and participate in a mock fire rescue to understand more about this main source of energy used to power our homes . Grab your hard hats and join us as we go crazy for coal! *SS *SC
Everyday Art with Ashley Jackson Art is everywhere! Learn how to take items you see, use, and even eat every day to create one-of-a-kind pieces. In this class you'll explore painting and creating using food, recycled materials and more! *AR
*Content Key: AR=Art DA=Dance LA=Language MA=Math MU=Music SC=Science SS=Social Studies TC=Technology TH=Theater O=Other
SYC Registration Form Please print!
Date:
Student: First ____________________ M.I. ____ Last_____________________ Preferred on Nametag ________________ (Optional) SS# _____- _____- ____ DOB:_____________________ Fall 2015 Grade ________ Please Circle One: Male Female School:____________________________________________________________ Parent or Guardian: _________________________________________________ Mailing Address:____________________________________________________ City_____________________________ St _______ Zip _____________ Day Phone: (______) _____ - ________ Email address: _____________________________________________________ Shirt Size (cirlce):
Youth Small Adult Small
Youth Medium Adult Medium
Youth Large Adult Large
Registration fee: $88.00 (Includes materials, snacks & SYC T-Shirt) Payment Method (circle): Check (Payable to MCC) Cash VISA MasterCard
____Other
Discover
Credit Card #: ________-________-________-________ Expiration Date: _____/______ Name on Card___________________________________ Signature _______________________________________
PLEASE COMPLETE BACK PAGE
Please select one class from each box for a total of three classes. CHOICE ONE Grossology
Koolinary Kreations
or
CHOICE TWO Totally Tribal
or
Cartoon Classics
CHOICE THREE Crazy for Coal
or
Everyday Art
Register by Phone, Mail or Walk-in: Madisonville Community College Workforce Solutions Office Brown Badgett Center, Rm. 280 Madisonville, KY 42431 (270) 824-8658 or 8659
Register Early! Enrollment is limited to the first 20 paid registrants in each class. Tuition refunds will be granted if requested in writing at least two weeks before your SYC begins. SYC Scholarships: A limited number of scholarships are available. Call 824-8689 for more information. MCC reserves the right to cancel any class.
MADISONVILLE COMMUNITY COLLEGE Workforce Solutions Youth Series Event RELEASE OF CLAIMS FOR DAMAGES: I, _____________________________________, parent of ______________________________ do hereby consent that said child may participate in Summer Youth College 2014 (July 13-16, 2015) and any Summer Youth College 2015 campus activities. In consideration of time spent arranging and supervising of above activities, I do hereby personally, on behalf of said child, absolve and release Madisonville Community College and Workforce Solutions Office from any claims of personal injuries which might be sustained by said child while at camp. ___________________________________ __________________________________ Parent or Guardian Signature Student Social Security Number (Optional) ___________________________________ __________________________________ Address Student Date of Birth ___________________________________ __________________________________ City State Zip Phone Number I hereby give Madisonville Community College permission to use the photograph of the student named on this form for publicity and promotion. The photograph may appear in the local newspaper or MCC’s website or newsletter. Student Name: ______________________Parent/Guardian Signature: ____________________ KENTUCKY COMMUNITY & TECHNICAL COLLEGE SYSTEM Medical Authorization Authorization to Release Information I authorize any Health Care Provider, Insurance Company, Employer, Person or Organization to release any information regarding medical, dental, mental, alcohol or drug abuse history, treatment or benefits payable, including disability or employment-related information concerning the patient, to any CIGNA company, the Plan administrator or their employees and authorized agents for the purpose of validating and determining benefits payable. This data may be extracted for use in audit or statistical purposes. I understand that I or my authorized representative will receive a copy of this authorization upon request. This authorization or a photo-static copy of the original shall be valid for the duration of the claim. __________________________________ Signature (Parent or Guardian if claimant is a minor)
_____________ Date
___________________ Phone No.
Payment Authorization: I authorize all current and future medical benefits, for services rendered and billed as a result of this claim, to be made payable to the physicians and providers indicated on the invoices. ______________________________________________ Signature (Parent or Guardian if claimant is minor)
_________________ Date