Students Name:

Students Grade: K12345

Students Class:

Main Contacts Name:

Email:

Home Phone:

Cell Phone:

Contact Name and Number in case of an emergency:

Any allergy and/or medical concerns?

NOTES:

I am interested in becoming a lead parent: yesno

By registering for Enrichment classes, I (Parent/Guardian) authorize the registered child to participate fully in the class and affirm that participant has no known physical problems that would limit his/her participation and agree to indemnify and hold harmless enrichment staff from any and all liabilities incident to my minor child’s involvement or participation in classes or workshops, even if arising from their negligence, to the fullest extent permitted by law.

I agree with the above statement:

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