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GiftedImpact Enrollment

GiftedImpact Enrollment Form

Student Name

First Name

Last Name

Date of Birth

YYYY

School Site

Barwell Road Elementary

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Grade

T-Shirt Size

Please explain any of your child's special needs?

Background/Ethnicity

Parent/Guardian Information

Primary Parent/ Guardian

First Name

Last Name

Relationship to child

Does child live with this individual?

Preferred method of contact:

Parent Phone

(###)

###

####

Does your child have allergies, special diets, or medications?

If yes, please list/describe:

Does your child have any additional needs?

If yes, please describe:

Does your child have any serious medical conditions?

If yes, please describe:

Emergency Contact Information

The emergency contact should not be the same as primary parent/guardian.

Emergency Contact Name 1

First Name

Last Name

Emergency Contact Phone 1

(###)

###

####

Do you give permission for your child to be released to this person?

Parent Consent/Release Form

I certify that my child who is hereby enrolled in TheGifted Arts, Inc. with this agreement, is in excellent health and may participate in the physical activities associated with the TheGifted Arts Program. I represent that my child has insurance through my own or an alternative insurance carrier. I understand that each participant must assume the risk and related financial responsibility that could result from participation in any activities. I agree to assume any risk and financial responsibility.

Pictures / Media (Please check one)

Do you grant permission to TheGifted Arts, Inc. to use pictures and video(s) of your child in any promotional material, as well as to post on TheGifted Arts Inc. website and/or social media outlets.

I grant Permission

I DO NOT grant Permission

Data /Surveys (Please check one)

We are seeking permission to occasionally survey enrolled members to measure student growth and program satisfaction.

I grant permission

I DO NOT grant permission