CSCR Registration for Nov. & Dec. 2018
Email address *
Student First Name *
Your answer
Student Last Name *
Your answer
Grade Level -- if you already filled this in for summer or fall you can skip down to the dates.
Current School or Collaborative
Your answer
Parent/s, Guardians, Backups Names
Your answer
Phone numbers
Your answer
Any allergies, conditions or situations you'd like us to be aware of?
Your answer
Primary Care Physician name, and office.
Your answer
Tuesday 3:30-5:30, Nov 13
Tuesday 3:30-5:30, Nov 27 (no meeting Nov 20)
Tuesday 3:30-5:30, Dec 4
Tuesday 3:30-5:30, Dec 11
Tuesday 3:30-5:30, Dec 18
I want more...
I hereby give permission for my child to participate in all CSCR activities including transportation. In the event of an emergency, I as the parent or guardian, understand every effort will be made to contact me/us, using the phone numbers and emails above, while prioritizing getting 911 services. In the event we cannot be reached, I/we hereby give permission to the physician selected to secure proper medical treatment which may include hospitalization, anesthesia, surgery or injection of medication for my/our children. I/we do for my child, myself, and our personal representatives, family, heirs and assigns, knowingly and freely waive all claims against and release and discharge CSCR and its officers, directors, agents, employees and volunteers from any and all liability, loss, damage and expense which may result from participation in CSCR programs. CSCR reserves the right to photograph CSCR participants for publicity purposes. *
Thank you! Susan prefers email for non-urgent arrangements and registration questions. Please add her phone number 857-231-1768 to your contacts. If you need us while on an expedition, please both text and call repetitively (since otherwise we would be disregarding calls when with students). Our location is on the log-out sheet, next to the door at CSCR. Please count up the number of sessions your registered for and multiply by $32.50. If this form is for the second student, multiply by $27.50. Write a check or use the "other donation" amount on our payment form at to jump to paypal.
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