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Starfish program registration 2020-2021
Please fill out and submit this form to register your child for Starfish. Additional documents are required and available at
Student Name *
Student Birth Date *
Student Contact Number (if any) *
Parent/Guardian First and Last Name *
Parent/Guardian Contact Number *
Parent Email address *
Student's School *
Please list all other after school activities and programs *
Please list any additional persons who are allowed to pick up your child from the program, and include phone numbers. *
Please list any food allergies or health concerns. *
Does your student have an IEP or 504? If so, you will need to fill out another form. Starfish has limited room for special needs students and cannot accept all applicants due to staffing and program space limitations.
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Please electronically sign this form signifying your consent and that you understand that your child must abide by all regulations, rules, and guidelines of the program, and that his/her enrollment may be terminated based on bad behavior, or other circumstances deemed unacceptable by center staff. Regarding your child, you do not hold Starfish Learning Center responsible for accidents, injuries, or death. You give Starfish permission to take your child on outings and events. You agree, personally and on behalf of the minor child named above, to assume all the risks and responsibilities surrounding your minor child's participation in Starfish Learning Center's after school's after school program and all its related activities. To the fullest extent allowed by law, you hold harmless and agree to indemnify Starfish Learning Center, its officers, directors, faculty, staff, volunteers, employees and agents, from and against any present or future claim, cause of action, loss or liability for injury to person or property, which said minor child may be liable to any other person, related to said minor child's participation in recreational activities at Starfish Learning Center, resulting from any cause whatsoever, and regardless of fault. Sign by typing your name and date. *
You hereby give Starfish Learning Center permission to take photos of your child during the program and related events for purposes of promoting the program. Photos may appear in print materials and on the world wide web via our social media channels, blog, website, and email. You are at lest eighteen years of age and have carefully read and freely signed this Liability Waver and Release Form (Minor Child). You understand and agree that no oral or written representations can or will alter the contents of this document. I agree that this agreement shall be governed by the laws of the state of Illinois (excluding its conflict of laws principles). Sign by typing your name and date. *
Parents may contact the executive director via email at or the board of directors at with any questions or concerns.
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