Nautilus Spring Enrichment Registration Form 2018-2019
CLASSES BEGIN JANUARY 7th- MAY 27th
Today’s Date
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Student's Grade
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Student’s First and Last Name
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Name of Parent/Guardian
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Parents’ Phone Numbers
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E-Mail (please print clearly)
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Put a Check in the box for program sign up:
TOTAL $______________ PAID BY: (CASH) or (Paypal) or (Credit Card)
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Credit Card No: ___________________________
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zip code
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Expiration
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Security Code
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Emergency Contact (other than parent named above)
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Relationship:
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Phone
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Medical Information
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Doctor and Phone
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Preference of Hospital (Parents will be contacted first in case of an emergency. We will call Fire Rescue for all major injuries)
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Allergies
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Medications
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Limitations or Special Needs
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AUTHORIZATION FOR RELEASE OF STUDENT FROM SCHOOL: List the names of persons either authorized or not authorized to take your child from school after the after school program. Your child will not be released to anyone not specifically authorized by you. 
Authorized/ Not Authorized:
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Please note that the Yearly Student Accident/Health Insurance is recommended to participate in NMS After School Programs. You may pay online at: www.k12studentinsurance.com The above insurance, or private accident insurance is the sole responsibility of the parent to purchase. *NMS WILL NOT BE HELD RESPONSIBLE FOR ANY ACCIDENTS INCURRED DURING THIS ENTIRE PROGRAM* Please Initial
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Tuition Policy: There will be no tryout classes or pro-rating for missed classes. All classes are priced according to amount of classes. No refunds or credits after the first week of classes begin- NO EXCEPTIONS! Please make sure your student does not have a conflict before signing up. Please Initial
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Liability Release: We do hereby release Nautilus Middle School and PTSA from all liability for any accident or injury that might be sustained through participation in any and all after school activity. Please Initial
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Photographic Release I hereby _______authorize _____ do not authorize NMS and staff to use and publish any photographs/video for any publication, brochure or other publicity material for NMS.
Please note that if classes are not full, we may have to cancel
Parent’s/Guardian’s Signature
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Date
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Any Questions, contact 1naxle1@gmail.com or alireiss5@aol.com
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