Education Registration Flyer

Education Registration Flyer

Use this form to register a student for the listed program. Completed registration and any required deposit secure placement. Registration Deadline:

Student Information

Date of Birth:    Student ID:    Grade / Program Level:

Parent / Guardian Contact (if student is a minor)

Primary Phone:    Email:

Program Selection & Fees

Select program (check all that apply):

Morning Enrichment Program (ages 6–10)

STEAM Afterschool (grades 4–8)

Summer Intensive (ages 11–17)

Other program description:

Preferred Start Date:    Scheduled Days / Times:

Full payment due upon registration

Installment plan (call for schedule)

Financial assistance or scholarship requested: Yes No

Emergency & Medical Information

Relationship:    Phone:

Is the student required to take medication during program hours? Yes No

Policies, Consent, and Acknowledgments

Enrollment Acceptance: Enrollment is subject to program capacity and receipt of required fees. The organization reserves the right to refuse enrollment for safety, capacity, or disciplinary reasons. Applicants will be notified in writing of acceptance or denial.

Fee and Refund Policy: Tuition and deposit amounts are due in accordance with the selected payment plan. Deposits are non-refundable except where the program is canceled by the organization. Refund requests must be submitted in writing; prorated refunds may be provided at the sole discretion of the organization and subject to administrative fees.

Behavior and Safety: The student agrees to abide by the program code of conduct. Serious or repeated misconduct may result in suspension or dismissal without refund. The organization will take reasonable measures to maintain a safe environment but is not responsible for injuries resulting from participation in normal program activities when reasonable supervision and safety measures are in place.

Liability Waiver: By signing below, the registrant (or parent/guardian if student is a minor) acknowledges and assumes the risk of participation and releases the organization, its employees, contractors, and volunteers from liability for incidental injury or loss except where caused by gross negligence or willful misconduct.

Photo and Media Release: I grant permission for photographs, video, and audio recordings of the student taken during program activities to be used by the organization for promotional, educational, and archival purposes unless I decline below.

I consent to use of media I do NOT consent

Data Privacy: The organization will collect and maintain records necessary for enrollment and safety. Personal data will be used only for program administration, emergency contact, and internal reporting in accordance with applicable law.

Acknowledgment of Policies (check each to indicate understanding and agreement):

Enrollment Acceptance Policy

Fee and Refund Policy

Behavior and Safety Policy

Liability Waiver

Additional Permissions

Permission to transport student for off-site activities: Yes No

Certification

By signing below, I certify that I am the student named above if over 18 years of age, or the parent/legal guardian if the student is a minor. I certify that the information provided is true and complete to the best of my knowledge. I have read, understood, and agree to the policies, consent statements, and acknowledgments contained in this registration flyer.

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