Register

Parent/Guardian - Contact Information

Parent/Guardian #1

First
Last
Ms. Mrs. Mr Other

Street Address
Town/City
State
Zip Code
Home Phone
Work Phone

Cell Phone
FAX
Email
Zip Code
Occupation
Employer

Parent/Guardian #2

First
Last
Ms. Mrs. Mr Other

Street Address
Town/City
State
Zip Code
Home Phone
Work Phone

Cell Phone
FAX
Email
Zip Code
Occupation
Employer

Child lives with
Person responsible for payment

Emergency Contact Information - Alternate Pickup/Release

Emergency Contact #1

First
Last
Home Phone
Work Phone

Cell Phone
Email
Relation to child

Emergency Contact #2

First
Last
Home Phone
Work Phone

Cell Phone
Email
Relation to child

Please list those people including in addition to parents/guardians who are permitted to pick up your child:

1:
2:
3:

In case of medical emergency contact:

Contact #1

Name
Phone
Relationship to Child

Contact #2

Name
Phone
Relationship to Child

Contact #3

Name
Phone
Relationship to Child

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.

Parent’s/Guardian’s Initials

I understand that the SMART EDUCATION CORP. will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.

Parent’s/Guardian’s Initials

Terms of Agreement

Photo Release

I hereby give permission for my child to be photographed during the Smart Education classes. I understand the photos will be used to keep a journal of activities, to share during powerpoint presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Smart Education and its affiliates.

Parent’s/Guardian’s Initials

Transportation Release(if needed)

I hereby give permission for the transportation of my child for official Smart Education activities by modes of transportation agreed to by the camp organizers.

Parent’s/Guardian’s Initials

The SMART EDUCATION CORP. its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Children's’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).

Guardian Signature:
Printed Name of Parent/Guardian:
Date:

Child

Parent/Guardian - Contact Information

Parent/Guardian #1

Parent/Guardian #2

Emergency Contact Information - Alternate Pickup/Release

Emergency Contact #1

Emergency Contact #2

Please list those people including in addition to parents/guardians who are permitted to pick up your child:

Medical Release Information

Insurance Information

Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?

Is your child allergic to any type of food or medication?

Does your child require a special diet?

The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.

In case of medical emergency contact:

Contact #1

Contact #2

Contact #3

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.

I understand that the SMART EDUCATION CORP. will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.

TUITION INFORMATION

Please select how you heard about the Smart Education.

Terms of Agreement

Photo Release

Transportation Release(if needed)

I hereby give permission for the transportation of my child for official Smart Education activities by modes of transportation agreed to by the camp organizers.