2010 PRINTABLE REGISTRATION FORM (Shrink page to fit.)
Child's name ___________________________________________________________ M___ F___ Telephone_____________________
Grade in Fall 2010 _______ Age by 06/20/09 ______ Birthdate ____________________ TAG _______ Other _____________________
School ____________________________________________________________ District ____________________________________
Health information _____________________________________________________________________________________________
Physician's Name _________________________________________ Telephone ___________________________________________
Dietary restrictions (Please be specific) ___________________________________________________________________________
____________________________________________________________________________________________________________
CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____
CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____
CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____
CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____
CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____
CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____
CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____
CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____
CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____
CLASS _________________________________________________ WEEK #_____ ALL-DAY ____ MORNING ____ AFTERNOON ____
Parent/Guardian _______________________________________________________________________________________________
Street address ________________________________________________________________________________________________
City _________________________________________________________ State _______________________ Zip ________________
Cell #___________________________ Home #______________________________ Work # __________________________________
Email: _____________________________________________ Other contact information: ____________________________________
Emergency contact name and phone _______________________________________________________________________________
Person(s) authorized to pick up child(ren) after class __________________________________________________________________
Where did you learn about our Summer Program? ____________________________________________________________________
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 ____________