Anchor & Arrow Registration

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Fall 2026

Location: First Baptist Church

505 N Grand Ave

Glendora, CA 91741

Student First Name *

Student Last Name *

Student's email *

Student Grade for the Upcoming 26/27 school year?

Student's Date of Birth *

YYYY

Which Monday classes will you attend in Fall 2026? Click HERE to see class descriptions and pricing. *

Build & Design Lab, Grades 9 & 10

Hands-On World History Lab, Grades 9 & 10

English Foundations, Grades 9 & 10

Required

Will your child attend Pathfinders Leadership class at 1:15 PM on Mondays? *

Yes, I give Anchor & Arrow staff permission to walk my child to Pathfinders and check them in.

No, my child will not attend Leadership class at Pathfinders and will be picked up promptly at 1:00 PM

A $50 non-refundable Registration Fee is required to reserve your spot. Zelle or Venmo to Shanna Jimenez at 626-497-3615 or pay on our website HERE *

Yes, I understand there is a $50 non refundable registration fee to hold my child's spot.

Name of Charter School if applicable? *

I understand that I will process all PO's in a timely manner. PO's must be submitted to your charter school before class begins to avoid out-of-pocket expenses.

Yes, I agree

Clear selection

I understand that all class fees are non-refundable after two weeks from the class start date. If I choose to withdraw before the end of the second week, I must submit a completed drop form, and a 50% refund of the class fee will be issued. *

Yes, I understand.

Primary Parent/Legal Guardian's First Name *

Primary Parent/Legal Guardian's Last Name:
*

Primary Parent/Legal Guardian's Cell Number

Primary Parent/Legal Guardian's Email *

Home Street Address *

City of residence *

Zip Code *

Secondary Parent/Legal Guardian's First Name (By providing this information, you give permission for your child to be picked up by this person). *

Secondary Parent/Legal Guardian's Last Name *

Secondary Parent/Legal Guardian's relationship to student *

Secondary Parent's/Legal Guardian's Cell Number
*

Secondary Parent's/Legal Guardian's Email
*

List any medical issues (and the severity, if relevant) that are relevant to an educational and social environment. *

List any allergies (AND the severity) OR insert N/A *

Has your child been prescribed an epipen?
*

Yes

Please acknowledge that Anchor & Arrow's Agreement provides, with limited opportunity for exception, that:

1. You are solely responsible for administering your child's epipen, AND

2. That you will keep the child's epipen in your possession at all times

Yes, I acknowledge I will have this responsibility if my child joins Anchor & Arrow.

My child is over 12 years old, can self-administer Epipen, and I wish to pursue a waiver.

N/A (not applicable)

List any learning issues (and the severity if relevant) that you believe we should be made aware of OR insert N/A. *

List any behavioral issues (and the severity if relevant) that are relevant to an educational or social environment OR insert N/A.

Do you acknowledge and agree that if a student has a behavioral issue that disrupts the learning environment, a parent or legal guardian may be required to remain in class or in close proximity to the student per Anchor & Arrow's Agreement? *

Yes, I acknowledge that a parent or guardian may be required to remain in class or close proximity to my child in the event of behavioral concerns.

List any social issues (and the severity if relevant) that are relevant to an educational or social environment OR insert N/A. *

Does the student require medication during the day?
*

Yes

If you marked "Yes,"please acknowledge that Anchor & Arrow's Agreement provides that:

1. You are solely responsible for administering your child's medication AND

2. You will keep your child's medication in your possession.

Yes, I acknowledge that I will have this responsibility if my child joins Anchor & Arrow.

N/A

Medical Insurance Company, Member ID#, and Group ID#

Emergency Contact #1, Last Name, First Name (By providing this information, you give permission for your child to be picked up by this person). *

Relationship to the Child *

Emergency Contact #1 Cell Number *

Emergency Contact #2, Last Name, First Name (By providing this information, you give permission for your child to be picked up by this person). *

Relationship to Child *

Emergency Contact #2 Cell Number *

Photo Permission

Do you give permission for Anchor & Arrow to use your child's photograph(s) for marketing purposes on our website and/or social media platforms?

Yes, I give my permission.

No, I do not give my permission.

Clear selection

Do you agree to make all efforts to have your students to class on time? Students arriving late to class disrupt the learning environment for others. *

Yes, I agree to make every effort to have my students to class on time.

Has your child ever been expelled or dismissed from, or asked to leave a school, educational program, or enrichment program for any reason? *

Yes

If the answer is yes, please provide any details about the dismissal here.

To the best of my ability, I have made accurate, true, and complete responses on this form. Any misrepresentation on this form is grounds for dismissal of your family from Anchor & Arrow. *

Yes, I understand any misrepresentation on this form, the Participation Agreement, or during the school year is grounds for dismissal.

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