Clone of Summer Connection Registration-June 2026

Scholars Academy Registration Form

For any questions and concerns, please contact the Camp Director, Dr. Lauren Serpagli, lserpagli@dominicanacademy.org
One-week session of the D.A. Scholars Academy will take place.

The program fee includes the experiments and supplies.

We ask that students bring their own lunch each day.

The program cost is as follows:

$750 - Monday, August 24th to Friday, August 28th from 9:00 AM to 2:30 PM daily

Refund and other policies:
- Absolutely no refunds will be issued.
- Attendance privileges will be suspended for all students whose fees are not paid by the session start.
- Sickness policy: There is no refund for days missed due to sickness.
Scholar Information
Student's First Name*
Student's Last Name*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Current School*
Grade as of Fall 2026*
Parent(s)/Guardian(s) and Emergency Contact Information
FatherMotherBothGuardianOther
Primary Parent/Guardian Name*

First NameLast Name
Primary Parent/Guardian Preferred E-mail*
example@example.com
Primary Parent/Guardian Mobile Number*
Format: (000) 000-0000.
Primary Parent/Guardian Work Number
Format: (000) 000-0000.
Parent2/Guardian2 Name

First NameLast Name
Parent2/Guardian2 Preferred E-mail
example@example.com
Parent2/Guardian2 Mobile Number
Format: (000) 000-0000.
Parent2/Guardian2 Work Number
Format: (000) 000-0000.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Format: (000) 000-0000.
Relationship to Student*
Medical Information
Physician Name

First NameLast Name
Physician Office Number
Format: (000) 000-0000.
Does the student have any allergies?
Does the student have any special medications?
Significant past illnesses, injuries, operations (Description and dates):
Media Authorization and Release
I consent to the taking of photographs, movies, videos, and images (the “images”) capable of reproduction in any medium of me or my children, or of children for whom I am the designated guardian, by Dominican Academy and its parents, affiliates, trustees, directors, members, officers, employees, volunteers, agents, contractors, and sponsors (the “School”).

I hereby grant the School the right to edit, reproduce, use and reuse images for any and all purposes, including, but not limited to, advertising, promotion, and display, and I hereby consent to the editing, reproduction, use and re-use of said images in any and all media in existence and all media yet in existence, including, but not limited to, video, print, television, internet, and podcasts.

I forever grant, assign, and transfer to the School any right, title, and interest that I and/or my child/children may have in any images, including negatives, taken of me and/or my child/children by the school. I hereby agree to release, indemnify, and hold harmless the School from any and all claims, demands, actions or causes of actions, loss, liability, damage, or cost arising from this authorization.
Consent GivenConsent NOT Given
Parent/Guardian Signature on Media Authorization and Release Consent*
Type your name
Statement of Cooperation
In making application for our child, it is our desire to have her complete the Dominican Academy Scholars Academy for 2026. It is also our understanding that the policy of the school is to make no refunds of summer program fees.

I understand and give permission for my child to take part in all program activities, including, but not limited to, activities such as sports, using public transportation, and leaving the school premises for sponsored trips and visits.

I authorize the program officials to administer first aid and/or take my child to a physician or hospital for emergency treatment in the event that it appears necessary and if neither parent (guardian) can be contacted.

I understand that camp activities may be affected by the local health climate. If campers are experiencing symptoms of illness, please contact the Camp Director, Dr. Lauren Serpagli, at lserpagli@dominicanacademy.org or 212-744-0195, ext. 110 before leaving your home for camp. In these cases, camp director will advise as to next steps, if necessary.

I accept the responsibility to provide medical/dental insurance to cover my child for any injury that may take place at the school or during the program activities. I will not hold Dominican Academy or the Summer Connection responsible for medical/dental fees, should my child incur an injury at the program or during a program activity.

I recognize the school's right to dismiss any student who does not respect our rules or cooperate in the education process.
Parent/Guardian Name (Printed)*

First NameLast Name
Parent/Guardian Name Signature acknowledging Statement of Cooperation*
Type your name
Dismissal Form
My child may leave Dominican Academy without a parent/guardianMy child will wait at Dominican Academy for parent/guardian to pick them up

Summer Connection Camp Payment:*

Scholars Academy 2026 Registration Fee$750.00

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Scholars Academy Registration Form

Scholar Information

Parent(s)/Guardian(s) and Emergency Contact Information

Medical Information

Media Authorization and Release

Statement of Cooperation

Dismissal Form