LAST NAME OF CHILD:

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FIRST NAME OF CHILD:

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GENDER:

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Date of Birth

Age:

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School Child Presently Attends

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Grade in Fall 2014

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Home Address of Child:

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Parent/Guardian Name:

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Relationship to Child:

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Home Phone:

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Cell Phone:

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Work Phone:

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Home Address (if different than child)

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Second Parent/Guardian Name:

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Relationship to Child:

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Home Phone:

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Cell Phone:

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Work Phone:

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Home Address (if different than child):

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PERSON(S) TO CONTACT IN CASE OF EMERGENCY

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Name:

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Relationship to Child:

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Home Phone:

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Cell Phone:

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Work Phone:

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Person, in addition to the above listed parent or guardian, to whom child may be released:

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IN THE EVENT OF EMERGENCY

In the event of an emergency, I hereby give permission to representatives of Paul Robeson Freedom School to transport the minor to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by the hospital or doctor.

Parent/Guardian initials:

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Family Doctor:

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Phone Number:

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Specific Medical Information

Medical Conditions (ie., asthma, food allergies, medication allergies, etc.)?

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Is the child taking any prescribed medication(s)?

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If yes, please indicate name of prescribed medication(s):

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Does the child have any physical limitations?

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If yes, please describe:

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Child’s Well-Being: Does your child have possible academic or behavioral issues?

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If yes, please describe:

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Is the child presently participating in any other organizational programs or activities?

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If yes, please describe:

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AGREEMENT:

1. The 2016 Paul Robeson Freedom School will commence on Monday, July 7, 2016 and will end on Thursday, August 13, 2016. 2. The cost for the 6-week program is $300.00 (including 1 Freedom School T-shirt. And all on-site and off-site activities). Free breakfast and lunch. 3. The non-refundable registration fee can be paid in full or a deposit can be made. A minimum $10.00 deposit must be included with the registration form for the program. 4. Children will be expected to behave responsibly and uphold the community agreements of the Freedom School, so as not to jeopardize the personal security or the life of any child or any person in attendance. Failure to do so may lead to suspension without refund of registration cost. 5. Any child who has engaged in conduct described in paragraph “4” shall be immediately removed from any further participation in the activities of the Freedom School and upon immediate notification to said parent/guardian. The parent/guardian listed in the registration form shall immediately remove the child from the Freedom School with no right to demand a refund for any remaining period of the Freedom School. 6. No child will be allowed to attend the Freedom School without having attended an orientation session with a parent/guardian prior to the commencement of the Freedom School unless good cause is shown and advanced permission is received for an exemption. 7. Parents or guardians will be responsible for any damage to any on-site or off-site personal or real property caused by a child’s intentional, reckless, or negligent conduct during the 8-week session and while said child is in the care and custody of the Freedom School staff. 8. I, hereby state that as a parent or guardian, I am authorized to give consent for my child to participate in the 2016 Paul Robeson Freedom School, and do hereby give my consent.

Initials of Parent/Guardian:

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Paul Robeson Freedom School Registration Form

IN THE EVENT OF EMERGENCY

Specific Medical Information

AGREEMENT: