Student's name
*
First Name
Last Name
Gender
M
F
Student's age
Student's birthday
*
MM
DD
YYYY
Mother's name
*
First Name
Last Name
Mother's cell phone
*
(###)
###
####
Email
*
Father's name
First Name
Last Name
Father's cell phone
(###)
###
####
Home address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency contact (Please list someone other than parent/guardian)
*
First Name
Last Name
Emergency contact phone
*
(###)
###
####
Please describe any medical conditions or food allergies your child has
Does your child have an IEP (Individualized Education Plan) or other special learning needs? Please type YES or NO. If YES, please provide specific details about your child's needs.
Please select a class
*
Monday only (Science Out Loud)
Tuesday only (Science Out Loud)
Thursday only (Heroes, Villains, and History's Mysteries)
Monday & Thursday (both days)
Tuesday & Thursday (both days)
How many days a week?
*
1 x per week
2 x per week
Does this student have siblings attending classes at The Cottage with other teachers? If so, please select all that apply.
How did you hear about us?
Friend or family member
Flyer
Charter school
Internet
Other
Will you be using charter funds to pay tuition?
Please select one
Yes
No
If using charter funds, please list which charter you are with?
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.
*
I hereby solely and expressly assume liability for all risks and waive any claim I might have against April Brennan 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 April Brennan and all agents acting on behalf of April Brennan 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 checking the box, I acknowledge having read and understood this release.
*
I hereby grant to April Brennan and all representatives permission to use any photograph or videotape taken during class and deemed by April Brennan to be proper, in any publicity for The Cottage, or other use specifically for the promotion and/or public awareness of The Cottage.
*
I give permission to use my child's photo
I do not give permission to use my child's photo
Today's date
*
MM
DD
YYYY
