The Family Learning Center’s  
                                          
Summer Middle and High School Fit Bit Fitness and Personal  Development Internship Program

APPLICATION

Application deadline is:  July 10, 2020			Registration fee: $50.00

Program Dates/Times:  

Dates: July 13th to August 14, 2020 Hours: Monday –  Thursday, 
TBA- one-on-one and virtual meeting
Scholarships are available

If you need an application for our high school summer school classes contact: blyle@flcboulder.org or Brenda Lyle 303-442-8979 ext. 111

How to Apply:

1.	Complete the application (type or print clearly), waiver and parent forms. 
2.	Parent or guardian SIGNS the waiver, parent permission and agreement forms.
3.	Please return the signed waiver, parent permission and agreement forms with the application.*	
4.	Return application and forms to:	     The Family Learning Center, 
     3164 34th Street, Boulder, Colorado 80301 
5.	Applications must be received by July 10, 2020

Our Summer Program:
1.	Each student who completes the entire five week program earns a $150.00 paid internship stipend
2.	Physical fitness and team building programs
3.	Personal Development 

* - Please note a completed application does NOT automatically secure a slot for students in the 2020  Summer Middle and High School Fit Bit and Personal Development Youth Development Program . Selected applicants will be contacted by May 20, 2019.  Return completed applications to FLC/Brenda Lyle at 3164 34th Street, Boulder, Co 80301

Student Information						    Today’s Date: ________________
Name (Last, First): _________________________________________  Sex: ______   Age: ________	
Address: __________________________________________________________________________

City: _______________________  State: __________  County:  __________  Zip: _______________

Home Phone #:  __________________________    Cell Phone #: _____________________________

Email address: ______________________________________________________________________

Birth date: ____/_______/_______     Grade level in fall 2018: __________    Current GPA:________

School (name, city): _________________________________________________________________

Parent information:
Father name:  ______________________________________________________________________
Mother name:  _____________________________________________________________________
Address:  _________________________________________________________________________
Phone number:  ____________________________________________________________________ 
Siblings name and ages:
  __________________________________________________________________________________

n you compete the entire Session(s) , if you are accepted?   No _____	Yes _______

If not, what dates would you have to miss?  _______________________________________________ 

Parent/Guardian Information

Name (Last, First): ___________________________________________________________

Address: ________________________________________________________________

City: ____________________  State: __________  County:  __________  Zip: ______________

Home Phone #:  ________________________	Email address: __________________________

Cell Phone (Mother/Guardian):  ___________________________________________________

Cell Phone (Father/Guardian):  ___________________________________________________

The Family Learning Center’s

2020 “Ignite Your Potential” ~ Middle and High School Students
Summer Fit Bit and Personal Youth Development Program / Internship Program

PARENT PERMISSION & AGREEMENT FORM

Please PRINT your child’s name below:

Last Name: _____________________________		First Name: __________________________ 

PARENT Name (Last, First):  _________________________________________________________

COSTS & TERMS for the Family Learning Center 2015 Summer Middle and High School Program:

1.	I agree to the payment schedule, refund policy, and other terms listed in the brochure and/or website.  Initial here: _____________
OR
2.	I/we will need a scholarship. Initial here: _____________

 By my signature below, I confirm the following statements:
•	I give permission for my child (named above), to participate in this summer program.  
•	I agree to the terms listed above.
•	I understand that my child should demonstrate a positive attitude, discipline, a commitment to complete the entire six-week program, and a commitment to follow all program rules and regulations.  I understand that parental commitment and involvement is a mandatory requirement for any student who is accepted into the program.

Facsimile signatures shall be deemed originals for purposes of this Agreement. 

_____________________________________________ 		_____________________ 
(Signature of parent or guardian)                                                       	  (Date)