Wrentham Summer Institute 2017 · Wrentham, MA 02093 ... Instructor- Ms. Walsh ... Enjoy the sunny summer days while creating your own masterpieces of tie-dye clothing

Wrentham Summer Institute 2017

WRENTHAM SUMMER INSTITUTE:

Our program runs from 9 am to 12 noon,

Monday through Friday (except the week of

July 4th). At the end of each day the

instructor will accompany your child outside

the school and wait with them until a parent

or guardian arrives for a prompt pick up.

SESSION DATES:

Session One: June 26-30

Session Two: July 3,5-7

Session Three: July 10-14

Session Four: July 17-21

SESSION FEE:

Received by May 31: $100

As of June 1: $105

As of July 1: $110

EXTENDED HOURS:

We are pleased to offer extended hours for

Summer Institute participants for all 4

sessions.

Monday-Friday 12:00-4:00

$125/session

GRADE LEVELS:

Please make note of the grade level

indicated for each course. It reflects the

grade your child will be entering in

September 2017.

LOCATION:

The Summer Institute will be based at the

Roderick School. Drop off and pick up will

be at the Randall Road entrance. Outdoor

classes will be assigned an indoor location

to meet in case of rain. Look for our

banners and our friendly staff members to

guide you on your first day of class.

HOW TO REGISTER:

Complete a separate registration form and

medical form for each child that you are

enrolling. Include a second choice for each

session your child is registering for.

You do not have to be a Wrentham resident

to register. If you are not a Wrentham

resident, please send the 2 registration

forms PLUS a copy of your child’s physical

form including immunizations.

Full payment MUST accompany your

registration.

Please send to:

Roderick Elementary School

ATTN: WSI- Lori DeTrolio

120 Taunton Street

Wrentham, MA 02093

Confirmations will be sent in June.

Refund requests will only be honored prior

to JUNE 1st minus a $10 processing fee.

NO REFUNDS will be honored after June

1st. Refund processing may take

approximately 4-6 weeks.

Please make checks payable to:

Wrentham Public Schools

Questions:

Please contact Lori DeTrolio

508-384-5430

[email protected]

Wrentham Summer Institute Course Description

Session 1- June 26th-June 30th

Motor Movement

Grade level- PreK-2nd

Get those fingers and legs ready to work! During this class we will be working on activities

that benefit fine and gross motor skills. For our fine motor skills we will be using playdough,

sand, shaving cream and other materials to strengthen fine motor skills in many fun ways!

Obstacle courses and other games will help us with our gross motor skills.

Instructor- Ms. Walsh

“Oh the Places We Will Go” Kindergarten Kickoff

Grade level- K

Calling all children entering kindergarten! Come and meet some of your future classmates!

Learn your way around the classroom and school. Parents, your child will have exposure to

the kindergarten word wall words and experience some new math activities. These lessons

will be aligned with the state common core standards. Give your child a JUMP START and

help them KICK OFF a fabulous year in kindergarten.

Please join, Mrs. Stephanie Buckley, Mrs. Sue Traversi and Mrs. Faith Williams as we

introduce your child to kindergarten here at the Delaney School. From arrival at the bus circle

and until dismissal from the same spot, we will follow a typical kindergarten schedule and

routine. Children will rotate from their classroom learning environment to other special

subjects including, art, music, technology, and of course physical education! This class will

take place in the Vogel School. Children will have an opportunity to visit the art and music

classrooms where they will have class in the fall. Activities will be planned in both locations.

Your child will also have class in the computer lab located in the Vogel, and will have an

opportunity to use some of the programs they will be using throughout the school year.

Finally, we will introduce your child to the awesome Delaney Playground!

We cannot wait to meet our future kindergarten students please consider joining us

Instructors: Mrs. Traversi & Mrs. Buckley

On Holiday

Grade level- K-4th

Do you love to celebrate the holidays? If you do, then come join the fun! Each day a different

holiday will be celebrated. Will you be my Valentine on Monday? How about catching a

Leprechaun on Tuesday. Let’s have a cook-out for the Fourth of July. Trick or treat and wear

a costume for Halloween. End the week with the most wonderful time of year, Christmas.

We will be busy decorating for each holiday, creating fun crafts, making and eating yummy

snacks, and playing holiday themed games. This week will be packed with

fun filled holiday activities.

Instructor- Mrs. Blake

Animal Antics

Grade level-K -6th

Come visit, and play with animals while we learn about them! We will have real animal

visitors like dogs, rabbits, guinea pigs, turtles, and birds. Each day we will have live animals as

our role models and friends while we learn interesting facts about the animal, do crafts, and

play games outside based on the animal of the day. We may do some food crafts too if the

animals don’t get too hungry!!

Instructor- Mrs. Foxx

Tie Dye

Grade level- K-6th

Welcome back to the very popular tie dying bonanza with Miss Brackett! If you love the look

of bright tie dyed shirts, head bands, sweatshirts, or even bandanas then this is the class for

you! Enjoy the sunny summer days while creating your own masterpieces of tie-dye clothing

and accessories. You can even bring in your own things from home to tie-dye! Some kids

even brought sheets and curtains! Do not miss out on this once a year celebration!! * Please

wear clothes you do not care about getting tie dyed.

Instructor- Miss Brackett

Jump Start to First Grade

Grade level- 1st

Would you like to learn what first grade is all about? Come spend a week getting ready for all

the fun in first grade! During our week together, you will get a sneak peek of what you will

learn in first grade, as well as a refresher (or introduction) to the fabulous places in our school!

Have fun making crafts, playing games, and learning new things!

Instructor- Miss Blake

Letterboxing and Water Fun Play

Grade level- 2nd -5th

What could be more fun than finding a hidden treasure? Finding a treasure and running

through the sprinkler, that’s what! Have fun, stay cool! Letterboxing is an intriguing mix of

hiking, puzzle solving, treasure hunting and rubber stamping. Throughout the week we will

spend time indoors and out. Each child will choose a code name, decorate a letterboxing bag

and create a few rubber stamps. They will be able to take all of their supplies home at the end

of the week. We will hike the school grounds and Sweatt Hill areas in search of hidden

treasures and end each day by cooling off with lots of water play fun!! So bring a towel,

sunscreen, bug spray, a water bottle and a snack and get ready for lots of fun!

Instructor- Mrs. Lynch

Games Galore!

Grade level- 2nd-5th

Do you love to play games? Come and hang out with your friends, play some of your old

favorites and learn some new ones too. Board games, card games, brain games, movement

games, challenge games (e.g. Minute to Win it), the sky is the limit. We will try them all! Do

you have a favorite game? You can bring that too.

Instructor- Mrs. Amy Farrell

Summer Reading Jump Start

Grade level 2nd- 6th

Do you LOVE to read? If so, this class is perfect for you!

With the library at your fingertips, begin your summer with a great book. Sign up for summer

reading at the Fiske Library and begin the journey to reach summer reading goals. Join with

friends and spend your mornings reading short stories, poems, plays or chapter books. We will

spend time in the shade outside and in the Roderick Library- sharing great stories and reading

together. At the end of the week, we will submit our minutes to the Fiske Library and receive

credit for our reading minutes.

Instructor: Mrs. Lopez

Art Projects

Grade level- 3rd-5th

Do you love art? Do you want to design your own projects? Join our class and design and paint

your own stuffed animal. In addition you will draw, sculpt, craft and play games.

Instructor: Mrs. Lovely

Pottermania

Grade level- 3rd-6th

Harry Potter fans, enter the world of Hogwarts and Harry Potter! Immerse yourself in the

adventures of Harry Potter and his friends. Join us as we read “The Cursed Child,” have Harry

Pottery experiences, such as getting sorted into Hogwarts houses, learn spells and learn to play

Quidditch. We will finish up with a trip to “Hogsmead” and some Butter Beer.

Instructor: Ms. DeTrolio

Scratch #111

Grade level 4th – 6th

In this program, the student spends the week learning how to create animations and games with

the Scratch software. In addition to class instruction and free time to explore Scratch, the

students will participate in breaks from the computer screen and learn about various computer

science topics. The students will create either a game or animation that they may present on

Friday.

Instructor: Miss Lopez

Kid Around and Be Kind Yoga


Lots of energy, lots of laughing, lots of fun! The special music in this yoga class will get you

moving, grooving, shaking, stretching, running, jumping, skipping, hopping and doing all things

yoga! Focusing on what you’re thankful for each morning, creating mindful crafts, and spreading

kindness in the community are all a part of this feel good class! You will deeply relax as you

journey into your very own ‘secret garden,’ and learn how to use your breath anywhere, anytime

to help you calm down and focus. No yoga experience necessary, start where you are, everyone

is welcome! See you this summer in Kid Around and Be Kind Yoga.

Instructor: Ms. Boocock

Session 2-July 3,5, 6, 7

Cupcake Heaven

Grade level- K to 6th

Do you love cupcakes? Do you love making them at home or with friends? If you said Yes

then this class is for you! At Cupcake Heaven we will be baking cupcakes and decorating with

frosting for an entire week!! Do you love chocolate? Maybe Vanilla? BOTH?! Take this

class and we will bake all flavors and even make your own pink or blue sparkly frosting!!

Have a gluten allergy? We can use gluten free baking mix so you can join in on the fun too!

Please note the kitchen is not a gluten free or peanut free baking kitchen. Boys and girls of all

ages welcome. * If you would prefer your child to eat his or her cupcakes at home following

class rather than during our class please kindly send in a note with your child.

Instructor: Miss Brackett

Beachy Keen Fun

Grade level K-2

Is summer one of your favorite seasons? Do you love the beach? Come have fun learning all

about the beach! We’ll play water games, like Drip, Drip, Drop and Fill My Bucket. Our

projects will include shell paintings, collages, t shirt decorating and photo frames. We’ll read

summer stories and culminate our week with a make your own sundae party! Can you say I

LOVE SUMMER? Please pack a snack, drink and towel daily. Feel free to wear a bathing suit

under your clothes.


"Fun with Bee Bots and so Much More"

Grade level 2nd-4th

Technology activities have been planned in several academic areas, and will provide

opportunities for students to work beyond this week long class with some of the programs they

have used. Children will delight using our new Bee Bots, purchased with the generosity of

W.E.S.T.! Students will be presented challenges, much like those presented in our "Coding"

lessons. Students will program Bee Bots to answer questions they have been presented with,

and will become comfortable with basic programming commands. Next, students will

complete science and social studies challenges in: Moby Max, BrainPop Jr., Gizmos and

ABCYA! Scratch Jr. and Computer Drawing with Kid Pix 4 will also be taught. This class will

surely spark and keep your child’s interests.

Please e-mail Mrs. Traversi with any questions at: [email protected]

Instructor: Mrs. Traversi

Summer Science

Grade level- 2-5

Get ready for totally hands on, amazing science experiments. We will be exploding volcanoes, making

marshmallow towers, writing in invisible ink, creating homemade bouncy balls and much more! We will

discover what happens when you combine Diet Coke and Mentos, all the while learning what causes these

reactions. Don’t miss out on the fun!

Instructor: Miss Blake

Tennis and Pickleball

Grade level- 2nd -6th

Are your rackets ready? We hope so, because this summer we are offering a combined class of tennis and

pickleball! During tennis class we will be teaching all the basics such as forehand, backhand, volleys and

serves. The students will even participate in tournament play. Pickleball class will be structured similarly,

however the court size, racket size, and rules will change a bit! For those who do not know much about

pickleball, please check out this video! http://www.nbcnews.com/video/nightly-news/54713899 You will see

how closely related the two sports truly are. By the end of the week, we hope you grow a love for the games!

Instructors: Mrs. Pitman & Mr. Moon

Act it out!

Grade level- 2nd-6th

Do you like to perform? Do you enjoy being a part of a play? This is the program for you! Throughout the

week we will work together to create a play! Everyone will have a part in the play. We will rehearse lines and

work on stage performance. On Friday we will perform the play on stage!

Instructors: Ms. O’Connell & Ms. Downing

Scratch ll

Grade level 4th-6th

Both beginner and advanced students are welcomed back to learn more about Scratch in this follow-up course

to Scratch I. In this hands-on course, students will interact with the software to explore more features and gain

new skills. In addition to class instruction and free time to explore Scratch, the students will participate in

breaks from the computer screen and learn about various computer science topics. The students will create

either a game or animation that they may present on Friday.


Reading Jump Start

Grade level- entering 7th

Set the perfect amount of time aside to prepare for 7th grade. Decide on which book to read, partner up with

some friends and work on your Active Reading Log throughout the week. We will develop a plan to make sure

you are on your way to a successful start to 7th Grade

If you are required to read 2 books, you can use the strategies you learn to continue on your own, or sign up for

another session.


http://www.nbcnews.com/video/nightly-news/54713899

Session 3- July 10th-14th

Indoor/Outdoor Summer Play

Grade level- PreK-K

Come join in the fun with old friends and new. We will read stories, have snack, play indoor and outdoor

games, and create fun summer crafts! Don’t miss out on this one time offering!

Instructor: Mrs. Byrne


Grade level- K

Calling all children entering kindergarten! Come and meet some of your future classmates! Learn your way

around the classroom and school. Give your child a JUMP START and help them KICK OFF a fabulous year

in kindergarten. Please join, Mrs. Buckley, Mrs. Traversi and Mrs. Williams as we introduce your child to

kindergarten here at the Delaney School. From arrival at the bus circle and until dismissal from the same spot,

we will follow a typical kindergarten schedule and routine. Children will rotate from their classroom learning

environment to other special subjects including, art, music, technology, and of course physical education!

This class will take place in the Vogel School. Children will have an opportunity to visit the art and music

classrooms where they will have class in the fall. Activities will be planned in both locations. Your child will

also have class in the computer lab located in the Vogel, and will have an opportunity to use some of the

programs they will be using throughout the school year. Finally, we will introduce your child to the awesome

Delaney Playground! We cannot wait to meet our future kindergarten students please consider joining us


Pretty Jewelry

Grade level- K-6th

Do you love beautiful pieces of jewelry? Do you love the look of beaded necklaces and rope bracelets but

don’t know how to make them? This course is for you! We will use all different types of beads, thread,

paracord, and gems to create our own jewelry. Think about all of the accessories you could be wearing

throughout the summer or on your first day back to school: Necklaces, Bracelets, Rings, oh my!


Cooking Creations

Grade level K-6th

Do you like to cook? Do you like sweets? We will be making yummy treats each day for you to take home.

Animal cupcakes, Jello oceans donuts, candy and much more, much more! This class will also include outside

playtime each day, reading books and doing crafts that go along with the food we make!!

Instructor: Mrs. Foxx

Jr. Detectives

Grade level K-3rd

During this exciting and mysterious class, the students will enjoy solving mysteries, playing iSpy, learning

how to spot objects in hidden picture puzzles and find hidden treasure. The students will work hard to create

their own treasure map and lead a friend with clues. We will have school wide treasure hunts and many

mysteries to solve. Throughout the week we will read about the mysteries of Cam Jansen and her

photographic memory and try to solve her mysteries.

Instructor: Ms. Walsh

Wilderness Survival

Grade level K-3rd

Calling all junior explorers! Join us as we dig into a week of wilderness skills and fun. We will make mini

survival kits to take home, build outdoor shelters, create bark boats, learn to whistle with acorns, and hike

around Sweatt Hill among other activities. Throughout the week we will learn to pack a daypack, practice safe

hiking, and use a compass. If you like the outdoors, you will love Wilderness Survival!

Instructor: Benson Colella

Creativity Unlimited!

Grade level 1st-6th

Have you heard about Wrentham's Destination Imagination program? Have you wondered, what's it all

about? During this week long program students will engage in similar activities to those found in the DI

program. Each day will start off with fun team building exercises, then move on to hands-on Instant Challenge

activities, like building a bridge with toothpicks and mini-marshmallows, or building a tower with spaghetti.

Students will be grouped together by grade and will experience the challenge of researching a given topic in

history and then rewriting that historical event in a new and creative way. Two sessions to choose from;

July 10 - 14 or July 17 - 21.

Instructor: Mrs. DeVore

Lego Science


What could be more fun than building with Legos and experimenting with science at the same time?! How

creative can you be? We will build Lego marble mazes, balloon and rocket powered cars, catapults, and boats.

How fast and how far will your car go? How far can you make your catapult throw? How much weight will

your boat hold before it sinks? Let’s find out!

Instructor: Mrs. Amy Farrell

American Girl Club

Grade level 2nd – 4th

Do you love American Girl Dolls? If so, then this class is for you! Come bring your American Girl doll for a

week packed with fun. We will make crafts for you and your doll and end the week with an American Girl ice

cream party! So, grab your doll and come join the American Girl Cub!


A Yummy Twist to Science Camp

Grade level- 2nd- 6th

Have you ever wished you could experiment science with food? Now you can! Come join Miss White and

Mrs. Thorton as we explore the fascinating world of science with food and hands-on experiments. From

apples to marshmallows, the possibilities are endless! We’ve revamped the activities this summer and are

excited to explore with new foods and new activities. The week will be filled with explosions, launching

marshmallows, messy hands and many more! We hope to see you there! Please note that all materials are

nut free.

Instructors: Miss White & Mrs. Thorton

Minute to Win It!

Grade level-3rd-6th

Do you love fast-paced games? How about competing against friends or yourself to beat your personal best?

In Minute to Win It Challenge, we will use common household and school supplies to create exciting

challenges and games. Impress your friends with the tricks you master like knocking down a single pencil

with a marble, volleying paper balls with clipboards, and stacking and balancing dice on a Popsicle stick in

your mouth! On our last day, we hold our final Minute to Win It competition and the winning team will be

crowned the Minute to Win It Champions!

Instructor: Ms. Blake

Web Design

Grade level 4th-6th

Do you ever wonder how your favorite website is made? In this class, students will discover how to create and

design basic webpages. The students will participate in breaks from the computer screen to learn about various

computer science topics. By the end of the week, students will have their own website design.








another session.


Session 4- July 17th-21st

I Believe in Fairies!

Grade level PreK-3

DO you believe in fairies? We do! In this class we will explore the world of fairies (and maybe a gnome or

two.) We will read fairy stories and create little fairy dolls. When weather cooperates, we will spend time

outdoors to practice fairy dancing and build natural homes for our fairies with some teeny tiny

materials. Create another fairy house to bring home. Sprinkle on some pixie dust and join us for a fairy

filled week of fun!

Instructors: Deb Colella and Charlotte Colella


Grade level- K

Calling all children entering kindergarten! Come and meet some of your future classmates! Learn your way

around the classroom and school. Parents, your child will have exposure to the kindergarten word wall words

and experience some new math activities. These lessons will be aligned with the state common core

standards. Give your child a JUMP START and help them KICK OFF a fabulous year in kindergarten.

Please join, Mrs. Stephanie Buckley, Mrs. Sue Traversi and Mrs. Faith Williams as we introduce your child

to kindergarten here at the Delaney School. From arrival at the bus circle and until dismissal from the same

spot, we will follow a typical kindergarten schedule and routine. Children will rotate from their classroom

learning environment to other special subjects including, art, music, technology, and of course physical

education! This class will take place in the Vogel School. Children will have an opportunity to visit the art

and music classrooms where they will have class in the fall. Activities will be planned in both locations.

Your child will also have class in the computer lab located in the Vogel, and will have an opportunity to use

some of the programs they will be using throughout the school year. Finally, we will introduce your child to

the awesome Delaney Playground!

We cannot wait to meet our future kindergarten students please consider joining us


Fun With Water

Grade level K-1st

Do you love to play in the water? Then, this fun water camp for boys and girls is for you! Bring your flip

flops, bathing suit and towel, snack and plenty of water! We will play games is a small pool, slide down a

slip and slide, run under a sprinkler and hose, play fun water games and much more! Come have a SPLASH

of a time!

Instructor: Mrs. Byrne

The Beauty Salon

Grade level K-6th

Welcome back to the second annual beauty salon with Miss Brackett! Do you love getting your hair done?

Do you love painting your nails? Love playing with make-up? If you said yes to any of these questions then

this class is for you! At The Beauty Salon we will paint nails, learn new hairstyles, and even put on a

fashion show at the end of our week! Feel free to bring any of your own beauty accessories such as nail

polish, makeup, or hair pieces. Sign up quick because this class fills up fast! *Please kindly send in a note if

you prefer your child not to use certain materials such as hair chalk or makeup.


Cooking Creations

Grade level K-6th

Do you like to cook? Do you like sweets? We will be making yummy treats each day for you to take home.

Animal cupcakes, Jello oceans donuts, candy and much more, much more! This class will also include outside

playtime each day, reading books and doing crafts that go along with the food we make!!

Instructor: Mrs. Foxx

Seussical Summer

Grade level K-2nd

It’s only just begun, Come on in and join the fun. We’ll learn about Horton, That’s for certain. Sit back and

relax, as we read the Lorax. How about some some Oobleck? You’ll think it’s so coolbleck. You’ll surely be

beggin’, To taste those green eggins. We’ll make one fish, two fish swimming in the sea, And after that, we’ll

plant a tree! Yes! Dr. Seuss, he is the one, you don’t want to miss the fun!

Instructor: Miss Blake

Perler Beads and More!

Grade level K-3rd

Students will get together to create different designs with perler beads. They will be able to share their

creations with the group and get ideas for their own. Each day we will have a different theme with different

patterns that will be available. We will also work on a new craft each day!

Instructor: Ms. Walsh

Games Galore!

Grade level- 1st -4th

Do you love to play games? Come and hang out with your friends, play some of your old favorites and learn

some new ones too. Board games, card games, brain games, movement games, challenge games (e.g. Minute

to Win it), the sky is the limit. We will try them all! Do you have a favorite game? You can bring that too.

Instructor- Mrs. Amy Farrell

Creativity Unlimited!

Grade level 1st-6th

Have you heard about Wrentham's Destination Imagination program? Have you wondered, what's it all

about? During this week long program students will engage in similar activities to those found in the DI

program. Each day will start off with fun team building exercises, then move on to hands-on Instant Challenge

activities, like building a bridge with toothpicks and mini-marshmallows, or building a tower with spaghetti.

Students will be grouped together by grade and will experience the challenge of researching a given topic in

history and then rewriting that historical event in a new and creative way. Two sessions to choose from; July 10

- 14 or July 17 - 21.

Instructor: Mrs. DeVore

Legos! Legos! Legos!

Grade level 2nd-6th

Calling all Lego builders! Come and explore the wonderful world of bridges, skyscrapers, planes and more

with Legos! Each session will be focused on building different structures, learning creative Lego building

techniques and other activities involving the exciting uses of Legos. Legos will be provided, but students may

also bring in their special Legos from home. Students will uses their imagination to recreate or envision their

own structures. Come and discover all you can do with Legos.

Instructors: Miss White & Mrs. Thorton

Insane Science

Grade level 3rd- 6th

Just as Einstein said “Play is the highest form of research”, so In this class we will be doing fun and crazy

science experiments and having fun at the same time! We will be learning about chemistry by creating Lava

Lamps, and rock crystals. We will explore life science by making our own fossils. We will even learn about

biology by extracting DNA from peas! On the last day we will do a fascinating experiment that will blow

your mind!! So grab a friend and join this class for some INSANE SCIENCE!


PROGRAMMIN' PROS

Grade level 4th-6th

In this introductory class, students will learn basic syntax for the programming language Python. In addition to

creating their own first programs, they will learn how languages like this one are utilized to build apps and

games. After class instruction free time on the computer will allow the new programmers to discover Python for

themselves. The students will participate in periodic breaks from the computer screen to learn about various

computer science topics, participate in logic games, work with algorithms, and learn about well-known

individuals and their technological breakthroughs.








another session.


Wrentham Summer Institute 2017 Registration Form

Child’s Name:________________________________________Grade Fall ‘17____________

Street City State Zip

Parent’s Name:_________________________Home Phone:_____________Cell#_________

Email: _____________________________________________________________________

SESSION 1: June 26th-30th

Course Name Extended Day

12:00-4:00

1st Choice

Yes- hours needed

2nd Choice

No

SESSION 2: July 3, 5, 6,7

Extended Day

12:00-4:00

1st Choice

Yes- hours needed

2nd Choice

No

SESSION 3: July 10th-14th

Extended Day

12:00-4:00

1st Choice

Yes- hours needed

2nd Choice

No

SESSION 4: July 17th-21st

Extended Day

12:00-4:00

1st Choice

Yes- hours needed

2nd Choice

No

Total # of sessions_____________________x $100 = Total Payment Due. Beginning June 1st, class fee is $ 105 – Beginning July 1st, class fee is $ 110

Please make checks payable to: Wrentham Public Schools

Mail registration form, medical form and payment to:

Wrentham Summer Institute- Roderick School- 120 Taunton Street- Wrentham, MA 02093

Date Received: Check # : Amount:

Wrentham’s Summer Institute 2017 Emergency Medical Form

Child’s Name: ______________________________________________Grade Fall ‘17____________

Street City State Zip

Parent’s Name:_________________________ Home Phone: _________________________

Cell Phone: ___________________________ Work Phone: __________________________

Please identify a contact in case of emergency when parent or guardian cannot be reached:

____________________________________________________________________________

Name Relation

____________________________________________________________________________

Home Phone Work Phone Cell Phone

Medical Information

Family Doctor: Telephone Number:

Family Dentist: Telephone Number:

Preferred Hospital

Insurance Provider:

Please identify any allergies, daily medications, or health problems your child has that we should be

aware of.

The above named has my permission to participate in the Wrentham Summer Institute 2017. I understand and accept the

condition that any member of the staff will not be held responsible for accidents, medical, or dental expense that are

incurred as a result of participation in this program. I further release the Wrentham Summer Institute 2017 and the

Wrentham Public Schools/Town of Wrentham from any and all claims.

I also understand that by signing below, I give the Wrentham Summer Institute permission to share this information with

staff and emergency personnel.

____________________________________________________________________________

Parent/Guardian Signature Date

This form MUST be retuned along with the registration form. If you are NOT a Wrentham student, please send a copy

of your current physical form including immunizations from your doctor.

Documents

Wrentham Summer Institute 2017 · Wrentham, MA 02093 ... Instructor- Ms. Walsh ... Enjoy the sunny summer days while creating your own masterpieces of tie-dye clothing