Student's Name *

First Name

Last Name

Student's Birthday *

MM

DD

YYYY

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

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does your child have siblings attending classes at The Treehouse with other teachers? (Select all that apply.) *

Karen Murray

Kristin Evans

Cynthia Vaccaro

Laura Ashmun

April Brennan

N/A

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 agree

I hereby solely and expressly assume liability for all risks and waive any claim I might have against Amy J Sachs 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 Amy J Sachs and agents acting on behalf of Amy Sachs 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 agree