Academic Enrichment Program - Application
Dear Parents/Guardians and Applicant:
Thank you for your interest in the Project Ring the Bell for Education After School Academic Enrichment Program offered by Woodstream Church and Academy. Please fill out this application form completely.
Project Ring the Bell for Education
Applicant Information
Applicant's Name
Your answer
Gender
Grade
Parent Information
Parent's/Guardian's Name
Your answer
Permanent Address (include street, city, state, zip)
Your answer
Parent Phone Number
Your answer
Parent Email Address
Your answer
Current School Information
Name of School Child Attends *
Your answer
Address of School Child Attends *
Your answer
School Dismissal Time *
Your answer
Emergency Contact Information
Contact #1 - Name *
Your answer
Address *
Your answer
Relation to Child (Aunt, Uncle, Sibling, etc . . .)
Your answer
Phone Number of Emergency Contact
Your answer
Contact #2 - Name *
Your answer
Address *
Your answer
Relation to Child (Aunt, Uncle, Sibling, etc . . .)
Your answer
Phone Number of Emergency Contact
Your answer
Authorization and Payment Information
Payment (select one) *
Medical Authorization Release *
I authorize and designate the representatives of the sponsoring organization set forth above to have authority during Academic Enrichment set forth above to act in our stead to authorize medical treatment, including hospitalization, for my child if deemed necessary by the chaperone or representative of the sponsoring organization. In granting this authorization, I am advising the representative that the medical treatment sought should be the best reasonably available and that cost is to be of secondary concern. I, on behalf of myself and my child, agree to release and hold harmless Woodstream Christian Academy and its directors, administrators, employees (in particular any chaperones identified who are employees of the School District) from any liability for personal injury to my child or damage to the personal property of my child unless such is caused by intentional misconduct by the directors or administrators of the School District and to indemnify and hold harmless the School District, its directors, administrators and employees for any claims asserted of the nature described in this paragraph. Please enter your name below for Authorization and Release.
Your answer
Parent Consent *
By entering my name below, I give permission and authorization for my student to participate in the Woodstream Academic Enrichment Program.
Your answer
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