Registration - Homeschool STEAM - May Programs

Name of child*

First Last

Age*

Grade*

Please Register my 5-14 year old for the upcoming Homeschool STEAM Program Series*

Tuesdays (Mar.)
Thursdays (Mar.)
Both Days (Mar.)

How did you hear about Homeschool Programs at The Phoenix School?*

Other: Please indicate

What Homeschool Groups and/or Preschools are you connected with?*

Parent's Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Preferred Phone Number*

Alternate Phone Number

2nd Parent's Name (if applicable)

First Last

Email*

Your Child's Allergies and other Medical Conditions*

Please list all allergies, including food, environmental and pharmaceutical. List any medical conditions or limitations. if none, please list "none".

I give permission to The Phoenix School to take, use, publish, and reproduce photos, slides, or videos of my child for its records and/or publications.*

Yes
No

Please indicate if we may use your child's photo.

The following waiver must be signed to complete registration:

Permission is granted for my child to participate in all planned Phoenix School activities; understanding that competent leadership and supervision will be provided.
I understand that programs that do not meet the minimum enrollment may be cancelled or changed

Digital Signature - Permission to participate*

Authorization for Medical and/or Surgical Treatment and for Release of Information

Every effort is made to contact and inform the parents or guardians in case of a medical emergency, serious injury, or illness when immediate medical or surgical intervention is deemed necessary. On isolated occasions the parents or guardian cannot be reached. Accordingly, they are requested to sign the following statement:

In the event of illness or accident involving our/my son/daughter, we/I hereby give permission to The Phoenix School, its officials, and the treating physicians, surgeons, and dentists, to secure and furnish medical, dental, or surgical care and treatment for him/her and to give, administer, and render any treatment or aid, including anesthetics or surgery, as is necessary to protect, preserve, and safeguard the life and health of our/my son/daughter.

We/I further authorize The Phoenix School to release information to facilitate the medical or surgical care of our/my son/daughter, as is necessary for the completion of a claim for health insurance.

I give permission to the Homeschool Day instructor to share information relevant to my child’s health condition with appropriate school personnel when needed to meet my/our child’s health and safety need.

Digital Signature - Permission to Treat and/or to Release Medical Information as per the above Authorization Form*

Total

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Registration – Homeschool STEAM

Homeschool Registration Form - March Programs

The following waiver must be signed to complete registration:

Authorization for Medical and/or Surgical Treatment and for Release of Information

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