Student Registration Kindergarten Enrichment & Science Class 2020-2021 Student's Name(required) Student's Date of Birth(required) I want to register for the Tuesday class which meets at First Presbyterian Church616 W. 10th Ave. 9am to 1pm I want to register for the Wednesday class which meets at Christ Community Church2222 W. 100th Ave. 9:15am to 1:15pmEach Student can only be registered for one class of these two classes per week. Contact Information Mother's Name Mother's best phone number Can this number receive text messages Yes No Mother's Email Father's Name Father's best phone number Can this number receive text messages Yes No Father's Email Which Parent is the primary contact? Mother Father Student's Home Address(required) Student's Mailing Address(required) School Affiliation and Billing The Kindergarten Enrichment and Science class is $650.00 per semester which includes facility use fees and most lab materials. Are you affiliated with a charter school such as Family Partnership or IDEA? Who is your sponsor or contact teacher? How would you like to be billed?(required) Please bill FPCS (I have added or will add the class to OLS) Please bill IDEA (I have listed or will list the class on my ILP) I prefer to self pay. Please e-mail me an invoice. Class fees will not be refunded for dropped classes after the first two weeks of class. Please check box below to acknowledge that you understand this policy. I understand that dropping classes after the first two weeks have class have completed will result in no refund.(required) Special Concerns or Considerations Please list any concerns or considerations Please list any medical or other needs that the instructor should be aware of. (allergies, asthma, learning challenges, etc.) Please list any and all food allergies. Emergency Contact Information Please list the name and number of someone who can be contacted in the case of an emergency if we are unable to reach you: Emergency Contact Name(required) Emergency Contact Telephone(required) Permission With this signature, I give my permission for my student to fully participate in the Kindergarten Enrichment and Science class (excluding anything listed in “special concerns” above). I also give permission for my student to go outside for recess with the class. Please sign by typing your full name:(required) Release of Liability I understand that although the students will be supervised by Heidi Asay and class aides, I do assume the risk in my student’s participation in classes. I acknowledge that I will not seek to have Heidi Asay or any other staff or helpers held liable in the event that any accident, injury, loss of property or any other circumstance or incident occurs during or as a result of my son’s/daughter’s participation in classes. This release of liability includes accident, injury, loss, or damages to the student, as well as, to other individuals or property which may result from the student’s participation in the event. I hereby release and agree to hold harmless Heidi Asay, Asay Enterprises AK, its officials, agents and employees and volunteers, from any claims arising out of my son’s/daughter’s participation in the event(s). I have read, understand and accept all of the statements listed above, and I accept full responsibility as described.(required) The information provided in this form is true and accurate. I agree to the permission and release of liability above. Please sign by typing your full name: Please sign by typing your full name:(required) Submit Share this:TwitterFacebookLike this:Like Loading...
