2009 PRINTABLE REGISTRATION FORM (Shrink page to fit.)
Child's name ___________________________________________________________ M___ F___ Telephone_____________________
Grade in Fall 2009 _______ Age by 07/01/09 ______ Birthdate ____________________ TAG _______ Other _____________________
School ____________________________________________________________ District ____________________________________
Health information _____________________________________________________________________________________________
Special interests ______________________________________________________________________________________________
Session 1 July 13-17
A.M. Class Title ____________________________________________________________________________________________
P.M. Class Title ____________________________________________________________________________________________
Session 2 July 20-24
A.M. Class Title ____________________________________________________________________________________________
P.M. Class Title ____________________________________________________________________________________________
Session 3 July 27-31
A.M. Class Title ____________________________________________________________________________________________
P.M. Class Title ____________________________________________________________________________________________
Session 4 August 3-7
A.M. Class Title ____________________________________________________________________________________________
P.M. Class Title ____________________________________________________________________________________________
Session 5 August 10-14
A.M. Class Title ____________________________________________________________________________________________
P.M. Class Title ____________________________________________________________________________________________
Session 6 August 17-21
A.M. Class Title ____________________________________________________________________________________________
P.M. Class Title ____________________________________________________________________________________________
Parent/Guardian _______________________________________________________________________________________________
Street address ________________________________________________________________________________________________
City _________________________________________________________ State _______________________ Zip ________________
Cell #___________________________ Home #______________________________ Work # __________________________________
Email address_________________________________________________________________________________________________
Emergency contact name/phone __________________________________________________________________________________
Person(s) authorized to pick up child(ren) after class __________________________________________________________________
Where did you learn about our Summer Program? ____________________________________________________________________
Would you like to carpool with another family? __________ From what area/neighborhood? __________________________________
May we share your email address with parents interested in carpooling from your area? ___________
I understand that Education Soaring, Inc. occasionally takes photographs of children in classes for public relations purposes. Names of students are not used in Education Soaring literature. Permission is granted to use my child’s picture without his or her name in Education Soaring literature. Because the news media's policies regarding the use of children's names is different from Education Soaring's policies, I understand that my child will not be allowed to be photographed or interviewed by any media group without me or my representative present or without my permission granted in writing.
Education Soaring instructors and volunteers hold exemplary records as dedicated teachers, volunteers and community citizens. Student safety is the top priority of all Education Soaring staff and every effort is made to ensure the well-being of participants in classes. I release Education Soaring, Inc., its officers, instructors, volunteers and school district personnel where classes are held from any and all liability for injury to my child arising out of his or her participation in the program.
Child's name _______________________________ Parent signature _______________________________________ Date ____________