Student's Name
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First Name
Last Name
Gender
Student's Birthday
Mother's Name
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First Name
Last Name
Mother's Cell Phone
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(###)
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####
Email
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Father's Name
Father's Cell Phone
Home Address
Emergency Contact (Please list someone other than parent/guardian.)
Emergency Contact Phone
Please describe any medical conditions or food allergies your child has:
Please select which class day(s) you would like for your child
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Monday only
Tuesday only
Wednesday only
Thursday only
Monday & Wednesday (both)
Monday & Thursday (both)
Tuesday & Wednesday (both)
Tuesday & Thursday (both)
Does this student have siblings attending classes at The Cottage with other teachers? If so, please select all that apply.
Will you be using charter funds to pay tuition? With your charter you will find me under Creative Explorers with Miss Cindy .
Please select one
Yes
No
If using charter funds, please list which charter you are with?
I hereby solely and expressly assume liability for all risks and waive any claim I might have against Cynthia Vaccaro or individuals acting in the capacity as agents of the organization (staff members, independent contractors, volunteers, etc.). I assume full legal liability for my child’s actions in class and release Cynthia Vaccaro and all agents acting on behalf of Cynthia Vaccaro from any claims made as a result of my actions. This release shall be effective and binding upon the parties, as well as their heirs, beneficiaries, assigns, successors and legal representatives. By typing name in box, I acknowledge having read and understood this release.
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I hereby grant to Cynthia Vaccaro and all representatives permission to use any photograph or videotape taken during class and deemed by Cynthia Vaccaro to be proper, in any publicity for The Cottage, or other use specifically for the promotion and/or public awareness of The Cottage.
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I give permission to use my child's photo/video
I do not give permission to use my child's photo/video
I agree to submit the $45.00 non-refundable registration fee with this form and understand that my child will not be enrolled until this payment is received. I agree to pay the full semester tuition, due and payable in full or in three consecutive monthly installments, beginning on or before the first day of the corresponding semester. Or, if I am using charter funds, I agree to pay the Semester Start-up tuition payment of $165, per student, per class, on or before the first day of the corresponding semester. I understand that my charter school will be invoiced for the remaining tuition and if for any reason my charter school does not pay, I am responsible for paying any remaining balance on or before the last day of the semester.
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