Enrichment Programs Registration Form 2017-2018 Calendar Year
NOW ENROLLING!!! All classes begin September 5th & end on May 25th. Space is limited per class program - register early to get your child's spot! $25 yearly registration supply fee must be paid in full in order to secure your child's spot. Monthly tuition per program varies in cost. Please refer to schedule to see when weekly classes are offered.

* Discounts Apply: For siblings, a child enrolled in multiple programs, and for military personnel. (Inquire within)

Please fill out the registration form completely below for all children in whom you are registering for classes. THANK YOU!

We look forward to having you and your child(ren) join us for learning and fun at eTeachingMe!

Parents/Guardian First & Last Name
Your answer
Phone Number 1
Your answer
Email Address
Your answer
Home Address
Your answer
Child's #1 Name Enrolling:
Your answer
Age
Your answer
DOB
Your answer
Allergies, Needs, or Medical Conditions (If none, type N/A)
Your answer
Please select the class program you are wanting to register child #1 for.
Note: Our Kinder Ready Program has a registration form all on it's own that will need to be complete upon enrolling due to specific guidelines and questions regarding your child. Please see website for the registration form link.
Required
Child's #2 Name Enrolling:
Your answer
Age
Your answer
DOB
Your answer
Allergies, Needs, or Medical Conditions (If none, type N/A)
Your answer
Please select the class program you are wanting to register child #2 for.
Note: Our Kinder Ready Program has a registration form all on it's own that will need to be complete upon enrolling due to specific guidelines and questions regarding your child. Please see website for the registration form link.
Emergency Contact
In case of an emergency situation, please list one local person that we can contact other than the parents/guardian listed above.
Your answer
Emergency Contact Phone #
Your answer
Emergency Contact Relationship to Child
Is this person also Authorized to Pick-up your child?
Note: All authorized to pick-up are required to show a valid photo ID at the time of pick-up, and must be 18 years or older.
Physician's Name
Your answer
Physician Phone Number
Your answer
Preferred Hospital
Note: Due to the nature or circumstance of an emergency medical situation, eTeachingMe has the right and authority to contact local medical emergency support, and patient will be transported to the nearest hospital.
Your answer
Tell us How....
We love to know where our families come from. Please select how you heard or found out about us below!
Drop Off & Pick Up Policy
For all classes, parent or guardian is required to drop child off at beginning of class time and efficiently pick up the child/person at the end of class time. For all classes & events, there will be a late charge of $10 for every 15 minutes that pick-up time is late. Due to our program needs, we enforce this policy to properly and efficiently manage our class’s schedules and the needs of all of our students.
Medical Emergency Consent
By signing your name below, you are agreeing and understand the following. I, the undersigned parent or guardian of the above named student, do hereby grant authority to the staff of eTeachingMe to render judgement concerning medical assistance in the event of an accident, injury, or illness during my absence.I give my consent for my family doctor to treat my child in case of emergency or if you are unable to contact him, please accept this form as your authority to use the doctor on call in the emergency room for any necessary emergency medical treatment.I also understand that in this instance, I will be notified by phone in regards to the situation, and I give permission for my child to be transported to the nearest medical center if treatment is needed.
Your answer
Payment Policy Consent
I understand that there is a $25.00 supply registration fee once a year; for each child and program you enroll in. The first month's tuition & registration fee is due in full at initial registration. I understand that I am to pay my child's tuition in full on the 1st of the month. If I fail to pay by the 10th, I will be charged a $15.00 late fee. If payment is not received, the student may be dropped from the class. I understand that if I mail my tuition, it must be postmarked by the 5th to eliminate any possibility of it being received any later than the 10th. I understand that all fees are non-refundable.
Credit Card Policy
By submitting my credit card information through the secure online registration process using the PayPal payment processing system, I authorize eTeachingMe to automatically charge my card for monthly fees on the 2nd of each month. I understand that I must give written notice to eTeachingMe before the 1st of the month if I decide not to continue classes or decide to use another payment option. If I do not do this by the 1st I agree that I will be charged for that month. I agree that a $25 registration fee will be charged to my card along with the first month's tuition upon office approval of my registration form. All accounts are set up for an automatic monthly e-pay (recurring payment) unless we are notified by the 1st of the month.
Member Policies
I understand that if my child drops a class, I must provide a written notice to the office. I understand that the payment for all classes will be my responsibility until the arrival of such notification. I understand that written notice must be received before the end of the child's last month. I also understand that some months have an extra class included in that month and I am not charged for that class. Therefore, during the year I receive a number of "free classes." These are considered make-up classes for holidays. Therefore, on short months, I will pay full payment. I grant to eTeachingMe the right to take photographs/videos of my child. I agree that eTeachingMe may use such photographs or videos for any lawful purpose, including such purpose as publicity, illustration, advertising and web content.
Release of Liability
By reading and signing this form, you are agreeing and aware that you are engaging in activities with Love N Learn At Home dba eTeachingMe that include but are not limited to physical exercise and use of equipment, facilities, training and learning instruction. Some of our activities could cause injury to you or others. You are voluntarily participating in these activities and assume all risks of injury and liability that might result. You agree to waive any claims or rights you might otherwise have to pursue, Legal or other action against Love N Learn At Home dba eTeachingMe, the facility's owners, officers, employees, or agents for any reason. You have carefully read this waiver and declare you are sufficiently physically fit for any of our activities in which may require physical abilities and exercise.
Signature of authorized parent/guardian
By signing below, you are agreeing to register the above named child/person for our enrichment learning classes. You have read and fully understand all class details, descriptions, and policies as stated above. This signature verifies understanding and acceptance of this registration.
Your answer
Signed this day
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Signed at this time
Time
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