Homeschool Enrichment Enrollment Form
Registration for HS Enrichment Classes
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Parent e-mail address *
Student's Name *
Gender *
Date of Birth *
Approximate Grade Level *
Class(es) in which your child is enrolling *
Parent's Full Name *
Address *
Phone Number *
Emergency Contact (Someone other than parents) *
Emergency Contact Phone Number *
Is the student being treated for any long-term medical conditions? (If yes, please explain.) *
Does the Student have any limitations in physical activity? (If yes, please explain.) *
Is the student on any medications? (If yes, please list.) *
Is the student allergic to any foods or medications? (If yes, please list.) *
Physicians Name *
Insurance Carrier *
Student's spot will not be held until payment has been made. Listed prices cover the entire semester. Waivers will need to be signed in person on the first day of class.
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