Student's Name
*
First Name
Last Name
Student's Birthday
*
MM
DD
YYYY
Student's Gender
*
M
F
Mother's Name
*
First Name
Last Name
Mother's Phone
*
(###)
###
####
Father's Name
First Name
Last Name
Father's Phone
(###)
###
####
Emergency Contact- please list someone other than parent/guardian
*
First Name
Last Name
Emergency Contact Phone
*
(###)
###
####
Parent's Email
*
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Please describe any medical/emotional conditions or allergies we need to be aware of:
Does your child have a formal diagnosis that may impact his or her ability to function in a classroom setting? Please type Yes or No. If yes, please provide specifics.
*
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 the class(es) you wish to register your child for:
*
Play & Learn Lab MONDAY (half day)
Learning and Laughing with Elephant & Piggie TUESDAY (full day)
Blooms and Bugs WEDNESDAY (full day)
Blooms and Bugs THURSDAY (full day)
MON (half day) & WED (full day)
TUE (full day) & THU (full day)
Does your child have siblings attending classes at The Treehouse with another teacher?
Will you use charter funds to pay your child's fees?
*
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 fees, 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 submit a purchase order (P.O.) on or before the first day of the corresponding semester. I understand that my charter school will be invoiced for the full amount 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 The Treehouse 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 The Treehouse and agents acting on behalf of The Treehouse 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 Karen Murray and all representatives, permission to use any photograph or videotape taken during class and deemed by Karen Murray to be proper, in any publicity for The Treehouse, or other use specifically for the promotion and/or public awareness of The Treehouse.
*
I give permission to use my child's photo/video
I do not give permission to use my child's photo/video
