2020 Mizizi Homeschool Co-op Enrollment Form
The Mizizi Homeschool Co-op serves to support African American home-schooling parents and their children. We are a grassroots effort founded to provide families with the tools they need to successfully home-school their children.

Email address *
Untitled Title
Contact Information
Parent Name *
Parent Phone Number *
Parent Address (Address, City, State, Zip Code) *
Parent Neighborhood
Second Contact Name *
Relationship to child(ren) *
Second Contact Phone Number *
Second Contact Email
Tuition
Our classes will be provided on a sliding scale basis. The suggested prices are below:
$15 monthly Decode
$15 monthly Science
$15 monthly Our Story
$25 Monthly Pan-African Literature
$25 Monthly Youth Entrepreneur Class
Would you like to be considered for financial assistance regarding tuition? Assistance and scholarships are limited and will be given based on need and availability.
Clear selection
If you answered YES- Are you receiving aid from the government in the form of WIC, SNAP, TANF, TEFAP or The HUD Public Housing assistance program? Please specify
If you are in need of financial assistance please express your need and share what you might be able to contribute financially or otherwise to the homeshcool. We encourage you to set a dollar amount you can contribute monthly even if it is nominal.
The undersigned grants permission to Play Cousins Collective to use photographs and videos of my child(ren) participating in Play Cousins Collective events and programs including during the Mizizi Homeschool Co-Op virtual classes. Photos and videos can be used for publicity, copyright purposes, illustration, advertising, and web content. Furthermore, I understand that no royalty, fee or other compensation shall become payable to me by reason of such use. Please type first and last name.
During our events and field trips children are consistently well supervised, however, accidents do happen. The undersigned(s) assumes) all risk of injury or harm to the child associated with participation in the Mizizi Homeschool Co-Op and agree(s) to release, indemnify, defend and forever discharge Mizizi Homeschool Co-Op, Play Cousins Collective and it's staff, employees, and agents of and from all liability, claims, demands, damages, costs, expenses, actions and causes of action in respect of death, injury, loss or damage to the child, or by the child, howsoever caused, arising or to arise by reason of or during the child's participation in the day care. During any in-person activities you are welcome to join us or call and check on your child ! We are honored to offer a safe, welcome and powerful space for your child(ren) to learn and play! *
COVID-19 RELEASE: While participating in events held or sponsored by Play Cousins Collective (“PCC”) “social distancing” must be practiced and face coverings worn at all times to reduce the risks of exposure to COVID-19. Because COVID-19 is extremely contagious and is spread mainly from person-to-person contact, PCC has put in place preventative measures to reduce the spread of COVID-19. However, PCC cannot guarantee that its participants, volunteers, partners, or others in attendance will not become infected with COVID-19.In light of the ongoing spread of COVID-19, individuals who fall within any of the categories below are not eligible to participate in person in PCC programming. By attending any PCC program or event, you certify that you or the participant you are registering do(es) not fall into any of the following categories: 1. Individuals who currently or within the past fourteen (14) days have experienced any symptoms associated with COVID-19, which include fever, cough, and shortness of breath among others; 2. Individuals who have traveled at any point in the past fourteen (14) days either internationally or to a community in the U.S. that has experienced or is experiencing sustained community spread of COVID-19; or 3. Individuals who believe that they may have been exposed to a confirmed or suspected case of COVID-19 or have been diagnosed with COVID-19 and are not yet cleared as non-contagious by state or local public health authorities or the health care team responsible for their treatment. Sign below: *
Mizizi Homeschool Co-Op offers homeschooling support and supplemental programming.
Mizizi Homeschool Co-Op is not a school. This program is to give home-schooled children (or traditional students schooling at home) the opportunity to practice their skills and explore their interests in a group setting.
Please do not list Mizizi Homeschool Co-op as the educational entity homeschooling your child. Our program is here to support the phenomenal work parents are doing to educate their youth and provide a community around that effort!
What are your goals for your child's education this year? *
What challenges would you like help facing as a parent or homeschooling family?
What are your child's interests and favorite subjects?
Child's name *
Child's birthday (Month, Day and Year) *
MM
/
DD
/
YYYY
What classes would you like to enroll your child in? *
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of Play Cousins Collective. Report Abuse