2021 REGISTRATION

We are very happy to be returning to the GFA campus for our PreK-8 Program this summer and are greatly looking forward to seeing our students in person! Please follow the directions below to complete the 2021 regsitration for each of your Horizons GFA students.

Each of the following items must be completed and submitted by May 20, 2021.

1. Teacher Assessment Form (for returning students only, not for students who applied and were admitted in 2021)

Students previously enrolled in Horizons GFA (i.e., not students newly admitted in 2021) need to have a Teacher Assessment Form filled out and submitted by their school year classroom teacher. Please copy this link and email to your enrolled child’s school year teacher: https://www.horizonsgfa.org/returning-student-teacher-evaluation-form/. We need this form for each of your enrolled children.

2. Connecticut Health Assessment Form: one form to be completed per student

This form was previously sent to returning students via Parent Square. If you haven’t started this process, please download and print the Connecticut Health Assessment, bring to your child’s doctor for completion then either email to mrutledge@gfacademy.org or mail to Horizons GFA Forms, 35 Beachside Avenue, Westport, CT 06880. If your child’s last physical is older than August 1, 2019, you will need to schedule an appointment for a new physical.

3. Emergency Medical Contact Form: one form to be completed per student

One form per enrolled child must be completed and submitted.

2021 HGFA EMERGENCY MEDICAL FORM

PLEASE FILL OUT ONE FORM PER HORIZONS STUDENT.
STUDENT INFORMATION
Student Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Gender
Student Birth Date
MM slash DD slash YYYY
PARENT/GUARDIAN INFORMATION
Parent/Guardian 1 Name
First Last
Parent/Guardian 1 Relationship to Student
Guardian 1 Phone
Guardian 1 Alternate Phone
Parent/Guardian 2 Name
First Last
Parent/Guardian 2 Relationship to Student
Guardian 2 Phone
Guardian 2 Alternate Phone
EMERGENCY CONTACT INFORMATION
Please provide the name and phone numbers of two relatives, friends, or neighbors who we can contact in the event we cannot reach you if necessary. DO NOT list parent or guardian as an emergency contact if already listed on this form above. An emergency contact must be willing to pick up your sick child at GFA if needed.
Emergency Contact 1 Name
First Last
Emergency Contact 1 Relationship to Student
Emergency Contact 1 Phone
Emergency Contact 1 Alternate Phone
Emergency Contact 2 Name
First Last
Emergency Contact 2 Relationship to Student
Emergency Contact 2 Phone
Emergency Contact 2 Alternate Phone
STUDENT'S MEDICAL PROVIDERS
Student's Doctor
First Last
Doctor's Phone
Dentist Name
First Last
Dentist Phone
STUDENT MEDICAL INFORMATION
Please answer the questions below to provide current health and medication information to staff. In the unlikely event of an emergency, this information may be shared with Emergency Medical Services personnel. Please notify the Horizons nurse immediately regarding any change in your child’s medical information.
1. Does your child have any medical conditions?
If yes, please list medical conditions below.
2. Does your child have any allergies?
If yes, please list all allergies below.
3. Does your child take any medications, either prescription or over-the-counter, on a daily or regular basis?
If yes, please list medications below.
4. Will your child require the administration of any medication, either self-administered or by the staff, while attending Horizons?
If you answered yes, please list all medications below that will be taken while on the GFA campus.
If you answered yes to this question, please print out and complete the Authorization for the Administration of Medication Form (http://www2.tmsc.org/CTMedAuthForm.pdf) or contact our office for one to be mailed to you. This form must be completed by the child’s authorized prescriber and signed by the child’s parent or guardian. Please submit the completed form to Horizons by June 10th. Medications must be delivered to the nurse by a responsible adult on the first day of the program.
PERMISSION TO ADMINISTER PAIN RELIEVER
ACETAMINOPHEN (TYLENOL): The Horizons nurse may administer Acetaminophen to a child for headache, menstrual cramps, orthodontic pain, or other pain according to the Standing Orders of the summer programs’ medical advisor, and the professional judgment of the nurse. The Standing Orders allow up to two (2) doses per month for students through 8th grade.
Please indicate your permission for the Horizons GFA Nurse to administer Acetaminophen (Tylenol) to your child as needed by placing your initials here. (If you do not initial, the nurse will NOT administer Acetominophen to your child in the event of issues listed above.)
IBUPROFEN (MOTRIN/ADVIL): The Horizons nurse may administer Ibuprofen to female students with menstrual cramps. If a student requires Ibuprofen more than four times in any given month, an order from the student's authorized prescriber is required.
Please indicate your permission for the Horizons GFA Nurse to administer Ibuprofen (Motrin or Advil) to your child as needed by placing your initials here. (If you do not initial, the nurse will NOT administer Ibuprofen to your child in the event of issues listed above.)
MEDICAL EMERGENCIES POLICY
In the event of a medical emergency, serious accident, injury, or illness, as determined by the GFA/Horizons nurse or another responsible staff member, it is the policy of Greens Farms Academy to call 9-1-1 immediately for EMS assistance and transport to the nearest approved medical facility. Emergency interventions, as ordered by the child’s physician or summer program medical advisor will be implemented in the interim, as appropriate. Best efforts, reasonable under the circumstances, will be made to contact you and/or your child’s doctor at the numbers you have provided on this form. Your child will receive medical care and treatment necessary to sustain life and/or stabilize his/her condition, as determined by the medical facility. Any further treatment must be authorized specifically by you, or the person(s) designated by you.
Parent/Guardian Name
First Last
By initialing below, I attest that I have read and understand the HGFA Medical Emergencies Policy.
Date Signed
MM slash DD slash YYYY

4. 2021 Student & Family Contract: one form to be completed per family

2021 STUDENT & FAMILY CONTRACT

You need to submit one contract per family. Horizons GFA offers quality programming that provides its students with the academic and social-emotional skills that will lead them to high school graduation and post-secondary completion. We expect that students, parents, and Horizons GFA will form a strong partnership to reinforce and achieve this goal, working together to create a supportive environment in which students enjoy their learning experiences, grow in confidence, and take ownership of their actions and education in order to succeed in school and beyond.
Please make sure that you discuss the contents of this contract with your enrolled child/children before signing in agreement. Multiple students can initial in the signature box. You need to submit only one contract for all students enrolled.
Parent Name*
First Last
Please list the name below of each of your children who are enrolled in Horizons GFA.
Student 1 Name*
First Last
Student 2 Name
First Last
Student 4 Name
First Last
Please review each section below with your Horizons student and initial where indicated.
COMMUNITY STANDARDS
The expectations for all members of the Horizons GFA community are guided by the following statements that apply at all times, whether on the GFA campus, off campus, or on the Horizons bus:
- I will treat everyone with respect, kindness and tolerance.
- I will be honest and behave in a manner that creates trust.
- I will contribute to a safe and supportive environment.
- I will respect the property of Greens Farms Academy and Horizons GFA as well as the personal property of others in the Horizons and GFA communities.
- I am responsible for my words and my actions.
- I will attend daily, participate, and try my best in all program activities.
- I will abide by the rules of Horizons GFA prohibiting use of personal technology while on the GFA campus unless granted permission by a Horizons staff member.
- I will consistently demonstrate that I value the opportunity I am being given as a member of the Horizons GFA community.
Parents & Students: By placing my initials below, I attest that I have read, understand, discussed, and will abide by the HGFA Community Standards & Expectations listed above.*
BEHAVIOR
The following behaviors are strictly forbidden in the Horizons GFA community: any form of violence, inappropriate touching of another student or teacher, physical, sexual, or racially based harassment, intimidation or bullying. Any of these behaviors will result in disciplinary action that might include suspension or expulsion from the program.
- Students will behave appropriately and regulate their behavior according to our high community standards.
- Parents will expect and encourage positive and healthy behavior from their child.
- Parents will follow up on any issue about their student's behavior brought to their attention by Horizons program staff.
- Parents will encourage appropriate behavior on the bus and follow up with their child in the event of reported issues.
Parents & Students: By placing my initials below, I attest that I have read, understand, discussed, and will abide by the HGFA Behavior Standards listed above.*
STUDENT COMMITMENT TO SUCCESS
- I will take ownership of my education.
- I will take responsibility for my behavior.
- I will persist in my schoolwork, and will seek help when needed.
- I will continually improve my organizational and study skills.
- I will be open-minded to new ideas and ways of thinking different from my own.
- I will listen to others with understanding and react with empathy.
Students: by placing my initials below, I attest that I have read, understand, and agree to the HGFA Student Commitment to Success.*
PARENT COMMITMENT TO STUDENT SUCCESS
I will play an active role in my child's social-emotional and academic growth with Horizons as a partner in order to achieve the goal of my child entering and completing the post-secondary program of their choice.
- I understand and value the role of education to my child's future and will communicate and emphasize its importance to my child.
- I will support and encourage my child to work to the best of his or her ability during the school year and at Horizons.
- I understand that if my child should require additional academic intervention, I will engage with and cooperate fully in the required intervention for the benefit of my child.
- I understand the relationship between attendance and academic success, and will commit to full attendance at the Horizons PreK-8 Program, High School Program, and during the regular school year.
- I will attend Horizons at GFA parent meetings and other events throughout the year to support my child and the community.
Parents: by placing my initials below, I attest that I have read, understand, and agree to the HGFA Parent Commitment to Student Success.*
PreK-8 ATTENDANCE
Attendance during the summer session and at Saturday Academy is mandatory.
- Summer absences are excused only for unplanned emergencies with a doctor's note.
- Family trips are to be scheduled around summer session dates and are not considered excused absences.
- Parents should schedule all non-emergency appointments (dentist, physicals, etc.) outside of program hours.
- Students with repeated absences will be placed on probation and risk being dismissed from the program.
Parents: by placing my initials below, I attest that I have read, understand, and will abide by the HGFA Attendance Policy.*
PARENT COMMUNICATION
I agree to complete all registration forms and submit the $30 per student registration fee no later than posted deadlines.
- I agree to promptly notify the Horizons office of any change in address, phone number or emergency contact.
- I agree to notify the Horizons office of an absence and reason for absence no later than 9:00am on the day being missed.
- I agree to participate in a minimum of one workshop per year.
- I agree to attend at least one on-site Horizons GFA event per year.
- I agree to send a copy of my child's year-end report card, IEP and 504 (as applicable) to the Horizons office at the end of each school year.
- I agree to send my child's End of Summer Report to his/her new school year teacher in September.
- I understand that students are not permitted to use their cell phones or other devices while on campus and agree that should I need to communicate with my child during the program day, I will do so by contacting the Horizons office.
Parents: by placing my initials below, I attest that I have read, understand, and will abide by the HGFA Parent Communication Policy.*
STATEMENT OF AGREEMENT
Parents: I have read, understand, and will abide by the HGFA Community Expectations listed on this form. I have discussed these expectations with my child. By typing my full name below, I attest that we will comply with the participation, attendance and behavioral standards of Horizons GFA.*
Date*
MM slash DD slash YYYY

5. Horizons GFA Permissions: one form to be completed per family

2021 HORIZONS GFA PERMISSIONS FORM

Students enrolled in the Horizons GFA summer and school year programs participate in a number of activities both on and off the GFA campus. These activities can include trips away from school premises, including but not limited to half or full-day field trips, regular trips to enrichment activities (i.e., swimming or rowing), or short walks on or adjacent to the GFA campus. Students will be accompanied at all times by responsible Horizons GFA faculty and staff members. If going off campus, properly trained and licensed drivers will provide transportation of Horizons students in chartered buses retained by Horizons GFA for these purposes.
Name of parent or guardian completing this form:*
First Last
You may list all your children enrolled in Horizons GFA on this one form.
Student 1 Name*
First Last
Student 2 Name
First Last
Student 3 Name
First Last
Student 4 Name
First Last
OMNIBUS PERMISSION TO PARTICIPATE
As parent or legal guardian of the above-named child/children, I hereby give permission for him/her/them to participate in all activities of Horizons GFA summer and school year programs. I hereby release Horizons GFA, Saturday Academy, and Greens Farms Academy from liability for any loss or damage sustained by me or my child because of an injury to my child/children while participating in, or being transported to or from Horizons GFA, Saturday Academy, Greens Farms Academy, or any field trip, regular activity or special event on or off the GFA campus.
I have read the permission items and place my initials below to indicate my agreement to the terms.*
Date*
MM slash DD slash YYYY
Permission to apply sunscreen or insect repellent
Horizons GFA students will spend time outdoors and in the sun as a regular part of program activities and field trips. With the approval of a parent/guardian, staff members will apply sunscreen or insect repellent to students only as needed during such activities and field trips. The sunscreen and/or insect repellent should be sent to the program with the student by the parent or guardian, clearly marked with the name of the student.
I authorize Horizons GFA staff to apply sunscreen my child.
- Yes for my child/all my children
- No for my child/all my children
- Other: I have multiple children in the program and need to specify permissons per child below
Sunscreen Exclusions: If you have multiple children in the program, please list which can and can't have insect repellent applied.
I authorize Horizons GFA staff to apply insect repellent on my child.*
- Yes for my child/all my children
- No for my child/all my children
- Other: I have multiple children in the program and need to specify permissons per child below
Insect Repellent Exclusions: If you have multiple children in the program, please list which can and can't have insect repellent applied.
Authorization for Use of Photographs
Photographs of our program in action is a critical piece of our ability to tell the Horizons GFA story in fundraising efforts. The child will not be identified in any use of any photograph. Photos are used in print, online, and video-based marketing and fundraising materials and other publications that support the Horizons at GFA program.
By typing in my name below, I, as legal parent or guardian of my minor child, consent that Horizons at GFA may use photographs of said minor child for any lawful purpose in ways described above.*
Date*
MM slash DD slash YYYY

6. Release of Information Authorization: one form to be completed per family

2021 HGFA INFORMATION RELEASE AUTHORIZATION

TO PARENTS: Please fill out and sign this form. You may list all your children enrolled in the Horizons GFA PreK-8 Program on one form.
I HEREBY GIVE PERMISSION FOR THE RELEASE OF SCHOOL RECORDS FOR EACH OF MY CHILDREN LISTED BELOW TO HORIZONS GREENS FARMS ACADEMY. Such records include, but are not limited to standardized tests (aptitude and achievement), current classroom grades or evaluations, teacher observations, and results of education, developmental and/or psychological evaluations. I understand that any information provided will be used to benefit my child's education and that it will become the confidential property of Horizons GFA. This permission form covers the period of January 1, 2021 through June 30, 2022.
STUDENT 1 NAME
First Last
STUDENT 2 NAME
First Last
STUDENT 3 NAME
First Last
STUDENT 4 NAME
First Last
PARENT NAME
First Last
CONSENT TO RELEASE OF INFORMATION
By typing in my name below, I authorize the release of my above-named child/children's educational records to Horizons GFA, including standardized tests (aptitude and achievement), current classroom grades or evaluations, teacher observations, and results of education, developmental and/or psychological evaluations. I understand that any information provided will be used to benefit my child's education and that it will become the confidential property of Horizons GFA.
DATE SIGNED
MM slash DD slash YYYY

7. Registration Fee

A $30 per student registration fee is due by May 20th. We accept checks, money orders, and this year we are also offering the ability to pay the fee online. Please do not send cash!

Please make checks or money orders out to Horizons GFA and write the name of your Horizons student(s) on the check and mail to:

Horizons GFA Registration
35 Beachside Avenue
Westport, CT 06880

2021 HGFA EMERGENCY MEDICAL FORM

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT INFORMATION

STUDENT'S MEDICAL PROVIDERS

STUDENT MEDICAL INFORMATION

PERMISSION TO ADMINISTER PAIN RELIEVER

MEDICAL EMERGENCIES POLICY

2021 STUDENT & FAMILY CONTRACT

COMMUNITY STANDARDS

BEHAVIOR

STUDENT COMMITMENT TO SUCCESS

PARENT COMMITMENT TO STUDENT SUCCESS

PreK-8 ATTENDANCE

PARENT COMMUNICATION

STATEMENT OF AGREEMENT

2021 HORIZONS GFA PERMISSIONS FORM

OMNIBUS PERMISSION TO PARTICIPATE

Permission to apply sunscreen or insect repellent

Authorization for Use of Photographs

2021 HGFA INFORMATION RELEASE AUTHORIZATION

CONSENT TO RELEASE OF INFORMATION

To pay the registration fee online, fill out the form below then click submit to put in credit card information.

2021 ONLINE REGISTRATION FEE PAYMENT

Horizons GFA (PreK-8 Program Office)

Horizons GFA Bridgeport (High School & College Office)

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2021 HGFA EMERGENCY MEDICAL FORM

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT INFORMATION

STUDENT'S MEDICAL PROVIDERS

STUDENT MEDICAL INFORMATION

PERMISSION TO ADMINISTER PAIN RELIEVER

MEDICAL EMERGENCIES POLICY

2021 STUDENT & FAMILY CONTRACT

COMMUNITY STANDARDS

BEHAVIOR

STUDENT COMMITMENT TO SUCCESS

PARENT COMMITMENT TO STUDENT SUCCESS

PreK-8 ATTENDANCE

PARENT COMMUNICATION

STATEMENT OF AGREEMENT

2021 HORIZONS GFA PERMISSIONS FORM

OMNIBUS PERMISSION TO PARTICIPATE

Permission to apply sunscreen or insect repellent

Authorization for Use of Photographs

2021 HGFA INFORMATION RELEASE AUTHORIZATION

CONSENT TO RELEASE OF INFORMATION

To pay the registration fee online, fill out the form below then click submit to put in credit card information.

2021 ONLINE REGISTRATION FEE PAYMENT

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Horizons GFA (PreK-8 Program Office)

Horizons GFA Bridgeport (High School & College Office)

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