Chicago Lights Summer Day Student Application 2025

Chicago Lights Summer Day runs Monday through Friday from June 23 through August 1, 2025.

Students entering 1st-6th grades in the 2025-2026 school year will spend the mornings in engaging and interactive Reading, Writing, and Math classes with elementary school teachers to increase skills and prevent summer learning loss.

Students entering 7th-9th grades will participate in career exploration and personal development experiences in the mornings through our Career Prep classes.

In the afternoons, all students will engage their creative sides with art classes in Singing, Dancing, Drama, Art, and Digital Music and with social-emotional learning opportunities in mindfulness and meditation, physical education, and Field trip Fridays.

Please fill out one application per child. We value small class sizes, so please be prepared for a waiting list. We do our best to accept as many students as possible while still keeping the program focused on each individual child.

Student's First Name

Student's Last Name

Street

City

State

Zip

Student's Gender or Gender Identity

If other, please explain:

Student Birth Date

If selected other, please answer:

PARENT/GUARDIAN INFORMATION

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Student

Parent/Guardian Email Address

Parent/Guardian Cell Phone

Parent/Guardian Work Phone

Parent/Guardian Home Phone

STUDENT CONTACT INFORMATION

Student Mobile

Student Email

EMERGENCY CONTACT INFORMATION

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Relationship to Student

AUTHORIZED CONTACT INFORMATION # 1

Please complete the below information for anyone other than you that is allowed to pick up your child/children:

Authorized Contact First Name

Authorized Contact Last Name

Authorized Contact Phone Number

Relationship to Student

AUTHORIZED CONTACT INFORMATION #2

Please complete the below information for anyone other than you that is allowed to pick up your child/children:

Authorized Contact First Name

Authorized Contact Last Name

Authorized Contact Phone Number

Relationship to Student

STUDENT SCHOOL INFORMATION

School

What grade will your student be entering in for the 2025-2026 school year?

School Type

If other, please explain:

PROGRAM INFORMATION

What size t-shirt does your child wear?

How many years has your child been in the Summer Day Program?

My child participates in the Chicago Lights Tutoring Program

Is your child eligible for free or reduced price lunch?

What is the student’s most recent report card grade in Reading? (If you do not know the grade, please estimate: ex. above average, average, or below average.)

What is the student’s most recent report card grade in Math? (If you do not know the grade, please estimate: ex. above average, average, or below average.)

Has the student repeated any grade levels?

If so, what grade(s)?

Is student enrolled in special education classes?

Does student have an IEP or 504 plan?

If Yes, what services/accommodations is your child receiving through his/her IEP/504 and what goals is s/he working on?

Does student have any health impairments?

If yes, please explain:

Is student currently on any medications?

If yes, please explain:

Does student have any dietary allergies or restrictions?

If yes, please explain:

What are your child’s strengths?

What are your child’s challenges?

When your child is frustrated, not focused, upset, sad, etc, what is the best way to help them work through those feelings?

What are your educational goals for your child?

Attendance is very important. Are you aware of any vacations, family visits, other camps, summer school, etc that may prevent your child from attending ALL weeks of Summer Day?

If yes, please explain:

In order for us to best meet the educational needs of your child, please upload a copy of their most recent report card here:

CAREER PREP PROGRAM

The Career Prep Program for rising 7th-9th graders is a unique summer experience that combines career exploration, academic and arts learning, experiential trips, and FUN! There is limited space available in this program, so we want to make sure the students that are most committed and ready for this program are selected. Therefore, please answer the questions below.

Parents, please share more about your child:

How would you describe your child?

How does your child resolve conflict?

Does your child prefer to work with others or alone in class?

Students, please answer the following:

What is your favorite subject in school?

What are your interests/hobbies?

What careers/jobs are you interested learning about?

Why are you looking forward to participating in this program?

When someone or something makes you mad or annoyed, how do you deal with that?

Please sign below if you and your child can commit to the following rules and expectations:

Upon entering class, students will be required to place their phones in lock box until the end of class.
Students must be ready and willing to actively participate; respect themselves, each other, and the staff; and resolve conflict that may arise.
If the above does not happen, parents/guardians will be contacted by staff:

First call home is a warning.
Second call home is a write -up and meeting with parent and student. In person or over Zoom.
Third call home is a temporary suspension from the program or loss of a field trip.
Fourth call home dismissal from program.

Please note: physical fighting and blatant disrespect towards staff members may result in immediate dismissal.

Parent Name

Student Name

Date

TRANSPORTATION

The Summer Day Program offers free bus transportation contracted by Ron’s Transportation to and from the program each day from the near north, near west and south side neighborhoods of Chicago at the following locations and times:

NORTH SIDE

8:00am - HALSTED ST. AND EVERGREEN ST.
8:05am – SEDGWICK AND BLACKHAWK
8:10am - MANIERRE SCHOOL (1420 N. Hudson)
8:15am - SEDGWICK AND GOETHE
8:20am - SEWARD PARK (Orleans & Division)

WEST SIDE

8:00am - ST. MALACHY (Oakley & Maypole)

If those bus stops are not convenient for you, parents may also drop off and pick up their student, or if old enough, students may walk or use public transportation. Please Note: Participants of Chicago Lights Programs who are under the age of 18 are prohibited from using ride sharing services, such as Uber and Lyft, as transportation to and from the program. If the parent/guardian is unable to transport the participant to and from the program, please do not send the participant to the program on that day. Additionally, volunteers and staff of Chicago Lights are not permitted to chaperone students on any ride sharing service.

Please select how your student will get TO the Summer Day:

If selected Chicago Lights Bus Service, please select which stop:

Please select how your student will LEAVE from Summer Day at the end of the day:

If selected Chicago Lights Bus Service, please select which stop:

Transportation Release

Please Note:

After Summer Day, students will be dropped off between 3:15 pm and 3:30 pm at the bus stops listed above.

You MUST stay with your child until the bus arrives and you MUST be present when your child is dropped back off at the bus stop.

The following transportation program release form MUST BE SIGNED by a parent for any student who uses the Summer Day bus service, provided by Ron's Transportation, Inc. After reading, YOU MUST enter your name.

I give permission for my child to use the Chicago Lights bus service, provided by Ron's Transportation. for the purpose of transportation to and from the Summer Day Program. I hereby release Fourth Presbyterian Church and Chicago Lights from any liability and assume full responsibility for the safety of my child at all times. I recognize that Fourth Presbyterian Church and Chicago Lights are not responsible for my child while walking to or from the designated bus stops. I understand that Fourth Presbyterian Church and Chicago Lights will utilize all reasonable safety precautions.

By checking the box below, I agree to the above Transportation Release.

I agree

Date

PHOTOGRAPHY AND VIDEO

The staff of Chicago Lights and Fourth Presbyterian Church periodically take photographs and video of our tutors, students, and staff for use in celebrating and promoting the work of the Chicago Lights Summer Day program. These images are among our most compelling representations of Summer Day and are vital to our effort to generate funding to support the program. These photographs and videos, which are used in print pieces and electronic communications, are used only by Chicago Lights and Fourth Church. They are never sold, nor are they used by other individuals or organizations without permission from those in the photographs. Similarly, no individuals in the photographs are ever identified by name without their permission. By completing this application, you agree that unless you indicate otherwise below, you grant your permission for Chicago Lights and Fourth Presbyterian Church to photograph or film your child and use such photos or videos in these ways to depict the work of the Summer Day program.

Please select one option below:

NON DISCRIMINATION POLICY

We want to make you aware of the non discrimination policy we follow and provide information on where to file a complaint when you need to. Thank you!

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation.

The completed AD-3027 form or letter must be submitted to USDA by:
1. mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights1400 Independence Avenue, SW Washington, D.C. 20250-9410; or
2.fax:(833) 256-1665 or (202) 690-7442; or
3.email:program.intake@usda.gov

This institution is an equal opportunity provider.

By checking the box below, I acknowledge the above statements:

I agree

TUITION PAYMENT

Tuition for Summer Day is $100 per student.

If you are registering more than one child from an immediate family, additional siblings are $50 each.

If your student is accepted into the program, you will receive more information on how to pay for the tuition with the confirmation letter.

Scholarships are available. Please reach out to Mark Dennison at mdennison@chicagolights.org to request. Thanks!

FIELD TRIP/OUTDOOR RECREATION PERMISSION FORM AND PROGRAM WAIVER

I, hereby give my permission for my student to attend all program-sponsored field trips and Outdoor Recreation Classes during the 2025 Summer Day Program. All field trips will be age-appropriate and include trips to the park, beach, museums and theaters. Outdoor recreation classes will include an hour of fitness with activities, including but not limited to: kickball, obstacle courses, softball and other outdoor games.

I understand that prior to each field trip, my child will be sent home with a notice of the place, date, time and method of transportation for the trip. If I do not want my child to attend a scheduled field trip, I will inform Mark Dennison at mdennison@chicagolights.org as soon as possible, and keep my child home the day of the trip.

I understand that for outdoor recreation classes, my child will go outside two days per week to our playground supervised by the outdoor recreation class Instructors. If I do not want my child to participate in the outdoor recreation class or if I have any concerns about my child’s ability to participate in the class, I will inform Mark Dennison at mdennison@chicagolights.org as soon as possible.

Furthermore, I understand that while Fourth Presbyterian Church and Chicago Lights will utilize all reasonable safety precautions during the 2025 Summer Day Program, I release and relinquish Fourth Presbyterian Church and Chicago Lights from any liability and cause(s) of action for any accident that may occur and assume full responsibility for the safety of my child at all times.

By checking the box below, I agree to the above statements:

I agree

Date

HIDDEN PE STAGE

HIDDEN PE LeadSource

HIDDEN

Set Client (checkbox) to TRUE

HIDDEN Role

HIDDEN Student Record Type ID