Student Name
*
First Name
Last Name
Student's Birthday
*
MM
DD
YYYY
Student's Gender
*
Male
Female
Parent Name
*
First Name
Last Name
Parent Phone Number
*
(###)
###
####
Parent Email
*
Parent Name
First Name
Last Name
Parent Phone Number
(###)
###
####
Parent Email
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 Number
*
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 describe any medical/emotional conditions or allergies we should be aware of:
Please select the class(es) you wish to register your child for:
*
MONDAY -
TUESDAY -
WEDNESDAY -
THURSDAY -
MON & WED (both)
TUES & THURS (both)
MON & THURS (both)
TUES & WED (both)
Does your child have siblings attending class Kaleidoscope Minds with other teachers? (Select all that apply.)
Will you use charter funds to pay your child's tuition?
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Yes
No
If yes, please let us know which charter:
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 Kristin Evans and Katrina Carleton 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 Kristin Evans, Katrina Carleton, and agents acting on behalf of Kristin Evans and Katrina Carleton 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 Kristin Evans, Katrina Carleton, and all representatives, permission to use any photograph or videotape taken during class and deemed by Kristin Evans and Katrina Carleton to be proper, in any publicity for Kaleidoscope Enrichment, or other use specifically for the promotion and/or public awareness of Kaleidoscope Enrichment.
*
Yes
No
Electronic Signiture
*
By entering your name below, you agree to the conditions set forth in this form.
First Name
Last Name
