Summer Immersion Application Checklist
Use this checklist to help you determine that your packet is ready to turn in! 
Application pages complete and signed by teacher & parents
Student Regulations Form complete and signed by student & parents
Media release complete with student name printed and signed by parent &
student
Swimming Permission Slip complete with student name printed and signed by
parent/s
Field Trip Permission Form complete with medical info, signatures and phone
numbers
Movie Permission Form complete with student named printed and signed by
parent/s
Check for $100 made payable to Pinellas County Schools (this will be returned
when students return their keys on the last day) Student name and “Key” in the
memo line, please
Check for $450 made payable to Pinellas County Schools **If you are a
scholarship recipient, modify amount accordingly [Pam Silva Scholarship (no
check), WLTA Partial Scholarship ($225)] Checks will not be deposited until the
week of May 2, 2017.
Please put a check in each section when you have completed it. When all sections are
checked, you’re ready to send in your packet!
Sending in your packet:
Option 1: Bring to the World Languages Office: Pinellas County Schools; 301 4th St. SW;
Largo, FL 33770; Call the office 588-6066 when you arrive
Option 2: Mail to: World Languages; Pinellas County Schools; 301 4th St. SW; Largo, FL
33770
Option 3: Give to your child’s teacher to send to us via interoffice mail (pony).
ALL PACKETS MUST BE RECEIVED BY 5:00 PM ON MONDAY, MAY 2.
When your packet has been received, you’ll receive an e-mail confirmation.
Questions? Need help?
E-mail or call:
Pam Benton 588-6066, [email protected]
Pinellas County School Board
41st Annual Spanish Summer Immersion Program
Held at Eckerd College
June 13 - June 17, 2017
Theme: “CUBA”
APPLICATION DUE IN OFFICE OF WORLD LANGUAGES, PINELLAS COUNTY SCHOOLS, PRIOR TO
5:00 p.m. MAY 1, 2017
THERE WILL BE NO REFUNDS GRANTED AFTER MAY 16, 2016.
ELIGIBILITY: Students entering grades 9 through 12 who have completed at least two years of
Spanish language study at the middle or high school level by June of 2017.
COST: $450.00 SUBMIT with this application:
1) Check for $100 made payable to Pinellas County Schools. Please write “Key” and you child’s name in
the memo area. This check will be returned to you when your child returns his or her key on the last
day of immersion. If your child loses his or her key, we will cash this check to pay Eckerd College for
the replacement.
2) Check for $450 made payable to Pinellas County Schools. Please write “Immersion” and your child’s
name in the memo area. If your child is selected to receive a partial scholarship, please note it below
on the application and include a check for $225. If your child received the Pam Silva Memorial full
scholarship, please note it below and do not include a check.
My child is the recipient of a scholarship: ____Pam Silva Memorial
Student Name
____WLTA Partial Immersion
Parent name_____________________________________
e-mail address________________________________________________________________________________________________
all communication will go to this e-mail address, be sure to list an address that is regularly checked
Address
City______________________________________________
State_____________Zip_____________________Phone__________________________________Sex ______Male______Female
Telephone (daytime) Father__________________________________________Mother_________________________________
Telephone (evening) Father__________________________________________Mother_________________________________
Other emergency telephone ______________________________________whose number is it?______________________
Age____________Birth Date______________________Birth Place____________________________________________________
Current School
Student ID. #__________________________________________
Grade entering, August of 2017__________I am or will be an International Baccalaureate student: Yes No
In August of 2017, I will enroll in Spanish: 2
3
4
5
6
AP
PreIB
IB (circle all that apply)
Please circle all that apply:
FLES (elementary school) K
1
2
3
4
5
School___________________________Teacher/s_______________
Dual Language Immersion K
1
2
3
4
5
School___________________________Teacher/s_______________
MS
6
7
HS
9
10
8
11
Name of School(s)__________________________Teacher/s______________________________
12
Name of School(s)__________________________Teacher/s______________________________
Highest level of Spanish completed (for high school credit)__________________________________________________
Last Spanish class taken____________________when?______________________where?______________________________
Why did you decide to participate in the Summer Immersion Program?_____________________________________
________________________________________________________________________________________________________________
What do you hope you will learn from this experience?______________________________________________________
________________________________________________________________________________________________________________
Current Spanish Teacher's Name:_____________________________________________________________________________
Current School Name & Address:_____________________________________________________________________________
Teacher's Recommendation (Please consider the student's ability, willingness to participate, behavior and
attitude)
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
__________________________________________________Teacher signature___________________________________________
please have the teacher complete this ON THIS FORM, teachers should NOT submit separate letters
Doctor's Name_______________________________________Telephone______________________________________________
Medication or Special Problem (i.e.: allergies, ANY meds prescription or non that your child might take
during the program. __________________________________________________________________________________________
________________________________________________________________________________________________________________
Roommate Request: (If you know you would like to room with another student applying for this
years program, please write that student’s name in this space.) ____________________________________________
Authorization: I/We hereby grant permission to my/our child to participate in the above Summer
Spanish Immersion Program. I/We authorize the School Board of Pinellas County and the administrators
and teachers in charge of the program to take all measures they deem necessary to ensure the protection
and well-being of my/our child. In consideration of participating in the program, I/we hereby release,
waive and hold the School Board of Pinellas County and all of its employees and agents harmless from
any and all claims, liability, and losses of any kind resulting from my/our child’s participation in the
program.
Signed: (Parent(s) or Legal Guardian):
Signature
Signature
____________________Date
____________________
For further information contact:
Pam Benton
PreK-12 World Languages Specialist
Pinellas County Schools
301 4th Street S. W.
Largo, FL 33770
[email protected]
Telephone: 727-588-6066
Or visit our website at: www.pcsb.org
Date
SUMMER IMMERSION STUDENT REGULATIONS
1. Students will abide by the Pinellas County Student Code of Conduct which includes
prohibition of:
o tobacco products, drugs, alcohol
o profanity
o co-ed visitation in dormitories
o leaving campus
o inappropriate dress (mid-thigh length shorts, sandals and t-shirt are acceptable;
no low-cut, backless, bare midriff or spaghetti straps for girls and no tank tops
for boys)
o bullying
2. Students will speak the target language.
3. Students will be on time for all events.
4. Students will abide by curfew hours:
10:00 - 10:30 p.m.
In dorms for small group sessions
11:00 p.m. Room check ----- everyone sleeping
5. Students may not:
a.
have outside visitors (unless previously authorized)
b.
order food from outside sources
c.
leave the dormitory after 11:00 p.m. (Students are to wake up the
instructor if a problem should arise after hours)
6. Students will use cell phone during designated "free time" only
7. Students will be expected to interact positively at all times with all campers and their
roommate and to be respectful of teachers at all times.
8. Positive behaviors and attitudes are expected at all times (including in rooms in the evening)
for the duration of the program.
Infraction of Summer Immersion Regulations
Infraction of any Pinellas County Student Code of Conduct rule will result in a call to parents
and immediate dismissal from the program without a refund of fees.
Infraction of other rules will result in: verbal warnings, extra chores, loss of free time, or call
to parents.
I have read, understand and will abide by the regulations outlined in this form.
Student Signature
date_____
Parent/Guardian Signature
date_____
___
Spanish Summer Immersion Camp June 2017
Pinellas County Summer Immersion Program
Swimming Permission Slip
(Student Name) ___________________________________________
has permission to swim in the Eckerd College Pool
during the week of the Pinellas County Summer
Immersion Program held at Eckerd College,
June 13-17, 2017. I understand that, although
there will be an Immersion teacher present at all
times, there may or may not be a certified life
guard on duty.
Parent/Guardian Name (Print)
___________________________________________
Parent/Guardian Signature
____________________________________________ Date: __________
Spanish Summer Immersion Camp
Baseball Game and Restaurant
June 14, 2017
x
4:00 PM
‘
9:00 PM
Summer Immersion Program Movie Permission
Dear Parents:
As a normal part of the curriculum, students will see a movie. Here is a link to the Internet Movie
DataBase information about the movie Viva Cuba that we anticipate showing this year:
http://www.imdb.com/title/tt0477916/?ref_=fn_al_tt_1
Although this movie has not been rated in the United States, the advisory in France and Argentina is
for 13 and over. Please click the parent advisory if you have any concerns. Please indicate below
whether or not you agree to allow your child to see this movie. If you choose to not allow your child
to see the movie, another activity will be provided.
If you have questions or concerns before signing the permission slip, please feel free to contact me.
[email protected]
Thanks,
Pamela G. Benton
My child’s name______________________________________
___My child may watch the movie.
___My child may not watch the movie.
_________________________________________________ ______________________
Parent signature
date