CSF - DC Scholars Summer Academic Enrichment Program 2026

CSF - DC Scholars Program
Summer Academic Enrichment Program Registration Packet

TBD
June 29, 2026 - August 7, 2026

First Name (as shown on birth certificate)

Middle Name (as shown on birth certificate)

Last Name(as shown on birth certificate)

Address

Apartment Number

City

State

Zip

Edit this text

Phone -- Mobile

By opting in to SMS messages, I understand that CSF-DC may occasionally send me text messages related to my academic journey, such as advising, registration deadlines, financial aid, etc. I can opt-out by texting STOP if I no longer wish to receive text messages.

Yes, I want to opt in and receive messagesNo, do not send messages

Phone -- Secondary Mobile

Phone -- Home

Email (Preferred)

name@domain.com

Date of Birth (Example: 2/2/2020)

Are you registered for SYEP?

YesNo

Please enter the last four digits of your Social Security Number (for SYEP purposes)

Current School

Do you have any special accommodations at school?

YesNoI am not sure

Grade for this upcoming school year

School attending 26-27 school year

Are you a member of Upward Bound?

If yes, what school are you currently enrolled?

Parent / Guardian #1 - First Name

Parent / Guardian #1 - Last Name

Parent / Guardian #1 - Home address

Parent / Guardian #1 - City, State, Zip

Parent / Guardian #1 - Relationship to applicant

Parent / Guardian #1 - Preferred phone number

Parent / Guardian #1 - Email address

Parent / Guardian #2 - First Name

Parent / Guardian #2 - Last Name

Parent / Guardian #2 - Home address

Parent / Guardian #2 - City, State, Zip

Parent / Guardian #2 - Relationship to applicant

Parent / Guardian #2 - Preferred phone number

Parent / Guardian #2 - Email address

Emergency Contact - In case of emergency please list an alternate contact - Name/Phone number/Email (different from your parent(s)/guardian(s) listed above)

Emergency Medical Information & Authorization

Full Name

Birthdate (MM/DD/YY)

Parent(s) / Guardian(s) Full Name

Name of Insurance Provider

Policy/Group #

Please upload a copy (front and back) of insurance card

A parent(s) / guardian(s) must complete the following -

I give approval for my student to receive first aid treatment and/or over-the-counter drugs if deemed necessary and appropriate should he/she become sick or injured while attending the CSF – DC Summer Academic Enrichment (SAEP) Program. This permission is extended to only College Success Foundation- DC staff. Please type your name in below

I give approval for my student

YesNo

Over the counter (OTC) medicines will only be administered upon your approval. A phone call will be placed to you before administering medicine for common ailments. These include but are not limited to the following;

Exception(s): In the event that your child has a special medical condition (or a religious preference) that prohibits the use of any over the counter drugs or items associated with First Aid care, please be specific and list them below

Illness/Allergy Information

Does your child have a medical/physical/ mental health condition (i.e. Diabetes, hyper-tension, epilepsy, asthma, depression, anxiety, etc.) which should be brought to our attention or addressed during CSF-DC programming?

YesNo

If so, please list the condition(s) along with a description of the symptoms, treatments, and/or ways we should address these health concerns

Does your child require medicine that must be administered daily?

YesNo

If yes, please list the medication:

Does your child have the ability and knowledge to understand symptoms and self - administer / medicate if needed?

YesNo

Does your child have any food or environmental allergies?

YesNo

If yes, please list:

How is this condition treated or addressed? (Medicine, Doctor's appointments, injections, etc)

Parent(s) / Guardian(s) signature & Date

Liability Waiver & Authorization for Medical Treatment

This form applies to all CSF - DC students/participants who intend to participate in the CSF - DC Summer Academic Enrichment Program. This form must be signed by the parent or guardian.

Authorization to participate in the Summer Academic Enrichment Program, which includes travel to and from Friendship Collegiate Academy and all program activities and trips during the six-week program.

·

Authorization to permit the Program Staff, or designees, to render and/or obtain medical treatment in the event that such a need should arise. All necessary precautions will be taken to avoid accidents and mental and/or physical health problems. However, Program officials must be in a position to act should such a need arise.

·

In the event of sickness or personal injury, I hereby authorize the Program staff and representatives, to secure all necessary medical attention for my child. I hereby authorize and give consent to any licensed physician or health care professional/ provider, to administer reasonable and necessary treatment. This authorization is also intended to cover emergency medical treatment.

·

This Authorization, releases the College Success Foundation- DC and all program representatives, employees, volunteers, and officers from any and all claims or causes of action for loss of property, mental and/or physical illness, personal injury or death sustained by the student arising out of any travel or activity conducted by, in support of, or under the auspices of this CSF-DC Summer Academic Enrichment Program.

Your signature constitutes your acceptance of the terms and conditions covered above.

Student Name

Parent Name

Date

Prescription Medication Authorization

Does your child require medication that must be administered daily?

YesNo

RX Medication Name

Dosage

Frequency of Administration

Time of day to be administered

If it is necessary for your child to receive/take prescription medication(s) that must be refrigerated or stored while attending the CSF-DC Summer Academic Enrichment (SAEP) Program, please provide:

- Specific directions for storage and/or administration

- Medication must be provided in the original or a duplicate box or bottle with the current prescription label on the container to a College Success Foundation employee upon arrival at CSF – DC SAEP.

It is understood that the medication is administered solely at the request of and as an accommodation to the undersigned parent or guardian. In consideration of the acceptance of the request to perform this service by any person employed by the College Success Foundation, the undersigned parent or guardian hereby agrees to release the College Success Foundation and its personnel from any legal claim which they now have or may hereafter have arising out of the administration of or failure to administer the medication to the student.

I hereby give my permission for my scholar to receive the above prescription(s) while attending the CSF-DC Summer Academic Enrichment Program (SAEP) as ordered. I understand it is my responsibility to furnish this medicine. Please type in your name below

If your child has asthma, allergies, or other respiratory issues that require medication daily, please answer the following;

Does your child carry an inhaler and can self - medicate ?

YesNo

Does your child carry an epi - pen, and do you want us to maintain and administer the epi-pen injection as necessary?

YesNo

Parent/Guardian Consent for Photographic/Video Release Form

My child has my permission to be photographed in the Summer Academic Enrichment Program (SAEP) and all other CSF-DC programming.

I further understand that my child’s selection as a College Success Foundation - DC participant may involve coverage by the media. I hereby release any claim I may have surrounding rights to my student’s name, image, voice, or likeness, and I agree that the Foundation, CSF, CSF-DC and Friendship Collegiate Academy and other partner organizations may use my child’s name, image, voice, or likeness in connection with publicity for the College Success Foundation - DC.

I verify that I have read and understood this document and agree to its terms. (Please type your name and date in the box below - Parent/Guardian)

I verify that I have read and understood this document and agree to its terms. (Please type your name and date in the box below - Scholar)

PLEDGE OF AUTHENTICTY, AGREEMENT AND CONSENT

Student Agrees (Signature)

Student Agreement Date

Parent/Guardian Agrees (Signature)

Parent / Guardian Agreement Date

If you have any questions or need help with the application, please reach out to dcadmissions@collegesuccessfoundation.org