Homeschool Registration Form Thursday Spring 2020 - 1st Student InformationStudents First Name*Nickname if PreferredStudent's Last Name*Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Gender*GirlBoyChurch Attended (if any)Parent/Guardian InformationParent/Legal Guardian's Name* First Last Parent/Legal Guardian's Relationship to Child*Parent/Legal Guardian's Cell Phone*Parent/Legal Guardian's Home Phone*Additional Parent/Legal Guardian's Name First Last Additional Parent/Legal Guardian's Relationship to ChildAdditional Parent/Legal Guardian's Cell PhoneAdditional Parent/Legal Guardian's Home PhoneEmergency Contact (Other than the names listed above)* First Last Emergency Contact Phone*List all people, INCLUDING YOURSELF, approved to pick up your child*Child's Health InformationFood Allergy*YesNoIf yes, please list specific food allergiesList Any Other Medical Conditions (asthma, etc.) or Activity RestrictionsAre all child's shots current*YesNoIf no, please explainPaymentThe payment for Foundry Homeschool Program will consist of one payment of $180 for the full 12 weeks. You must submit your online registration by February 3, 2019 to secure your child’s spot. A separate registration form must be filled out for each student you are registering.Child's Medical Consent(I) (We) the undersigned, parent(s)/guardian(s) of the registrant above, a minor, do hereby authorize the adult sponsors of the Foundry Center for the Arts, as agent(s) for the undersigned, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care, which is deemed advisable by, and is required to be rendered under the general or special supervision of, any physician or at the hospital or other health care facility. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, and is given to provide authority and power on the part of the aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which may be determined by a physician or surgeon, as aforesaid, to be advisable in the exercise of his/her best judgement. By typing my name below, I am signing this agreement.Electronic Signature*Date* Date Format: MM slash DD slash YYYY Crowd Release NoticeThis notice serves to announce that filming, taping, and or photography will take place at the Foundry Center for the Arts during Foundry Homeschool Program. By entering our campus, you grant the Foundry Center for the Arts the right to photograph you and your dependent children, to record your voice and to use your likeness without compensation. You also agree to release the Foundry Center for the Arts from any liability in connection with the taping/video production in perpetuity. Video and still images produced from Foundry Homeschool Activities may be used by The Foundry Center for the Arts in print publications (e.g. flyers, brochures) or video productions. Video and still images may be posted to the Foundry Center for the Arts website and social media pages. By entering the Foundry Center for the Arts campus, you agree to allow your image to be used for these purposes.Electronic Signature*Date* Date Format: MM slash DD slash YYYY Almost Done...
