1. 2013 SUMMER
PROGRAM
Creative Minds International Public Charter School is happy to offer a summer school program filled with
a wide variety of fun learning opportunities that support students’ social-emotional and academic goals.
In addition, the program will offer students the following activities: field trips, music, dance, yoga, and
sports in addition to other enrichment opportunities. Explore, create and have fun with us this summer!
Schedule
July 8th to August 2nd (4 weeks), 9:00 a.m. to 2:00 p.m. at our
school building (3224 16th Street NW). If interested, you can enroll
for all 4 weeks by filling out the attached registration form. Weekly
registration will not be available.
• Students can be dropped off beginning at 9:00 a.m.
• Breakfast will be served between 9:00 a.m. and 9:30 a.m.
• You can choose to enroll your child in the lunch program (by
checking this option on the registration form).
• Late pick up will be charged at a rate of $2/min past 2:00 p.m.
• Activities will begin at 9:30 a.m.
Cost
English Language Learners (ELL) and Extended School Year (ESY)
students are required to participate and will therefore not be
charged.
Students eligible for free or reduced meal plans: $50.00
All other students: $400 (with lunch: $495)
These fees will allow us to provide our students with various field trips and other enrichment activities
throughout all 4 weeks of the program.
3224 16th Street NW Washington, DC 20010 • 202.588.0370
www.creativemindspcs.org
LIMITEDSPACESPLEASE REGISTEREARLY!

2. 2013 SUMMER PROGRAM
Registration Form
July 8th to August 2nd (4 weeks)
9:00 a.m.— 2:00 p.m.
Student Information
Name ____________________________________________________________________ M ☐ F ☐
Birthdate & Year in School _________________________________________________
Qualifies for National School Lunch Program? Y or N
Qualifies for Extended School Year or is English Language Learner student? Y or N
Do you want lunch provided daily ($95/4weeks)? Y or N
Medical History
(i.e. allergies, physical limitation(s) & special considerations)
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Emergency Contact Information
Name _____________________________________________________________________
Address ___________________________________________________________________
Parent/Guardian 1 Work Phone _______________________ Cell/Other Phone _______________________
Parent/Guardian 2 Work Phone _______________________ Cell/Other Phone _______________________
Email Address _____________________________________________________________________
Doctor’s Contact Information
______________________________________________________________________________________________________
______________________________________________________________________________________________________
3224 16th Street NW Washington, DC 20010 • 202.588.0370
www.creativemindspcs.org
Please attach your payment (check or money order) with this registration form to
reserve your child’s space by February 28, 2013
Reimbursements for withdrawing from the summer program are as follows:
• Full reimbursements before June 1st
Please Turn Over

3. Acknowledgement of Liability - Field Trips
My child has permission to participate in activities/field trips as part of the Creative Minds International
Public Charter School (CMIPCS) summer program. I understand that the necessary safety precautions
will be taken for supervision during these activities/field trips using DC public transport/rented
transportation or walking.
Liability and Medical Waiver
The parent/legal guardian agrees to hold harmless CMIPCS, all CMIPCS personnel, and the owners of
any properties in CMIPCS made available for summer school activities, from any claims, damages,
losses and/or expenses arising out of participation in summer school activities and to assume all liability
for any and all personal injury, bodily injury, illness or property damage that occurs as a result of
participation in such summer school activities. The parent/legal guardian also warrants that participation
in this summer school is voluntary and that the student and the parent/legal guardian understand the
inherent risks involved in summer school activities, and the student agrees to all rules and policies
mandated by summer school personnel.
The students’ parent/legal guardian warrants that the student is physically fit and able to participate in
summer school activities, and consents to any employee, agent, or other personnel affiliated with the
CMIPCS summer school personnel, to seek medical attention and treatment or other measures deemed
necessary or advisable in the discretion or judgment of CMIPCS personnel for the above-named student
in the event of an accident, sudden illness, or other condition that occurs while the above-named
summer is in the care or under the supervision of CMIPCS personnel.
In case of an emergency, the school has my permission, to take my child to the emergency room at the
nearest hospital, if I cannot be reached. The hospital and its medical staff have my authorization to
provide treatment that a physician deems necessary for the well being of my child. I recognize that
CMIPCS does not provide medical insurance for my child and my child is physically able to participate in
the activities listed above.
The parent/legal guardian signing this form releases CMIPCS, and all CMIPCS personnel from and of any
liability for such decisions or actions in seeking medical care, and agrees to pay all the costs and fees for
the medical care or treatment authorized under this emergency medical authorization.
____________________________________________________________
Parent or Guardian’s Name (please print)
____________________________________________________________________________________
Parent or Guardian’s Signature Date
PLEASE RETURN THIS COMPLETED FORM TO CMIPCS ADMIN
For more information, please contact Sebastien at 202.588.0370 or sebastien.durand@creativemindspcs.org.
3224 16th Street NW Washington, DC 20010 • 202.588.0370
www.creativemindspcs.org
OFFICE USE ONLY DATE: ____________ TOTAL: ____________ CHECK:

4. NOW Available with
AFTER CARE Option Until 5 p.m.
We’re happy to offer a summer school program filled with a wide
variety of fun learning opportunities that support students’ social-
emotional and academic goals. The program will also offer
students the following activities: field trips, music, dance, yoga,
and sports in addition to other enrichment opportunities.
Explore, create and have fun with us this summer!
Monday, July 8 – Friday, August 2
9 a.m.-2 p.m. / After Care Option Until 5 p.m.
Limited Registration
Contact
Sebastien Durand
sebastien.durand@creativemindspcs.org
2013SUMMER
PROGRAM