Summer 2012 Enrichment Program Application

Student's first name:  Last name:

Student's nickname:

Parent 1 : -- title -- Mr. Mrs. Ms. Miss Dr.   First:  Last:

Parent 2 : -- title -- Mr. Mrs. Ms. Miss Dr.   First:  Last:

Lives with: Parent 1 Parent 2 Both Other:

Primary email address:

Parent 1

Street address:

City: ,  State:   -- select -- Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Home phone: Work phone:

Cell phone:

Parent 2

Street address:

City: ,  State:   -- select -- Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Home phone: Work phone:

Cell phone:

Student's Date of Birth: Age as of 6/1/12:

Current School:
Current Grade and Teacher:

Has your child previously received instruction in any of the following:

Wilson Reading System - Frequency: Step Achieved:
Lindamood-Bell - Frequency:
Any Orton-Gillingham based program
RAVE-O
Math
Writing

Areas of strengths and needs of your child that you wish to be addressed via our summer program:

If your child is not an applicant to our 2012-13 school year program, it would be helpful if you would send copies of any previous psychoeducational testing or school information that could assist us in working with your child. Please mail to the address at the bottom of the form.

Health information: (allergies, medications, chronic conditions):

Physician prescribing any medication taken during summer program:

Name: Phone:

Please read carefully, check the appropriate box based on program selection and then submit this form. Clicking Submit indicates agreement with the following:

I agree to pay the stated fee named on the application for AIM~Academy In Manayunk Summer Program. I understand that:

• A $100 application fee is to accompany the application for non-AIM families
• A deposit of 50% must be paid the day of the placement evaluation or by March 1, 2012 if not paid prior
• Full payment is due on or before May 1, 2012
• Any payments made after May 1st must be in the form of a bank check, money order, cash or credit card (3% fee for credit card)

Please check the program(s) for which you are applying:
Elementary Enrichment Program (entering grades 1 - 5) 9:00 AM to 12:30 PM, $2095
Upper School Enrichment Program (entering grades 6 - 12) 9:00 AM to 12:30 PM, $2095
Penn Charter Day Camp (entering grades 1 - 8) 12:30 PM to 3:30 PM, +$865
Penn Charter Sports Camp (entering grades 1 - 8) 12:30 PM to 3:30 PM, +$865
Penn Charter After Camp Program (entering grades 1 - 8) 3:30 PM to 5:45 PM, +$10/day - AIM campers interested in After Camp should contact and pay Penn Charter directly.

Please select any services for which you would like to receive information:
Interactive Metronome, All Grades, 15 sessions, +$1500
Cogmed Working Memory Training, All Grades, 25 sessions **
Individualized Occupational Therapy, All Grades, **
Individualized Speech and Language Therapy, All Grades, **
Psychoeducational Evaluation, All Grades **

**Contact Psychological Services Dept.

Please share with us how you learned of AIM~Academy In Manayunk’s Summer Program:

After completing the application form, you will have the option of paying by credit card. If you prefer to pay by check, please make payable to "AIM" and mail to:

AIM~Academy In Manayunk Summer Program
1200 River Road
Conshohocken, PA 19428