Learning Extension Center Student Registration
Thank you for your interest in attending a Learning Extension Center. We are committed to supporting your family during COVID-19 by providing a safe space for students to complete remote learning while following CDC and local health guidelines.
Parent/Guardian Name *
Student's Name *
Student's Birthday *
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Learning Extension Center my student would like to attend *
Student's Gender
Clear selection
Student's Grade *
Student's School *
Please list any allergies and/or dietary restrictions *
Please list any handicaps or limitations *
Additional medical information
Parent/Guardian Phone Number *
Please notify Catalyst for Columbus if your phone number changes by emailing olivia@catalystforcolumbus.com
Secondary Phone Number *
Email *
Mailing Address *
City *
Zip Code *
Please list the first and last name of a person other than the parent or guardian authorized to pick up the student or to whom the student can be released to in the case that the parent or guardian is not available to drop off/pick up their student *
Photo Identification must be provided by this person at pick up.
Parent/Guardian Authorization of Participation *
I give permission for my child to attend Catalyst For Columbus Programming. I understand that there are certain risks of damages and injuries, including death, inherent in traveling and other related activities incidental to my child’s participation, and I am willing to assume these risks on behalf of my child. These risks include, but are not limited to, those hazards associated with weather conditions, travel, and other participants. I hereby release and discharge Catalyst For Columbus as well as its directors, officers, administrators, employees, coordinators, volunteers, other agents and other parties of interest, from all claims, demands, grievances, and causes of action of every kind whatsoever, including but not limited to, all which may arise from or out of any injury incurred by my child while in attendance of the programs or enrichment activities and all injuries arising from the negligence of any of the above while traveling to this activity via private transportation. I further agree to hold harmless and fully indemnify Catalyst For Columbus as well as its directors, officers, administrators, employees, coordinators, volunteers, other agents and other parties of interest from any and all claims, damages, costs, including attorney fees, and causes of action, which may arise from any cause of action made by me or by, through or on behalf of my child, even if the damages, injuries or death are caused in whole or in part by any of the persons or entities hereby released.
Required
Photography Consent
I grant full permission and authority to Catalyst For Columbus and their representatives to photograph my child and to use, publish, and release for publications such photos. Photos taken by Catalyst For Columbus may be used for Catalyst For Columbus publicity or other purposes without remuneration or other considerations. Please let Catalyst For Columbus staff know if you do not want you child photographed by emailing olivia@catalystforcolumbus.com. The name of the child may be used in connection with the above, with the understanding that there is to be no exploitation of him or her and that any photographs so used should conform to standards of good taste.
Medical Authorization *
I hereby give permission to medical personnel selected by Catalyst For Columbus to order X-rays, routine tests, and treatment for my child, if he or she becomes ill, and in the event I cannot be reached in an emergency. I hereby give permission to the physician selected by Catalyst For Columbus to hospitalize, secure proper treatment for, and order injection and/or anesthesia and/or surgery for my child as named here. I further agree to be financially responsible for all such medical services. I hereby give permission for my child to participate in screenings and testings, which may identify additional services which may benefit my child. This form may be photocopied for use at any Catalyst For Columbus activity.
Required
Release to Transport *
I hereby give full permission for my child to be transported by the staff, mentors, volunteers or other representatives from Catalyst For Columbus. I hereby release and discharge Catalyst For Columbus and any and all parties of interest from all claims, demands, grievances and causes of action of every kind whatsoever, including but not limited to, all which may arise from or out of the injury incurred by my child while being transported to and from Catalyst For Columbus activities.
Required
School Release *
I hereby give permission to Catalyst For Columbus and area community schools to exchange information regarding the minor child listed on this application. The purpose of the exchange is to help both organizations better prepare the student to be successful in life. I also hereby give permission for my child to be visited by a representative (staff or assigned member) from Catalyst For Columbus.
Required
FAITH-BASED *
I give permission for my child to participate in Catalyst For Columbus's programming which is founded on Jesus and the Bible.
Required
Miscellaneous *
I understand that Catalyst For Columbus is not responsible for lost or stolen items.I understand that Catalyst For Columbus is not, nor claims to be, a licensed day care center.
Required
By signing my full name below, I acknowledge I have read the complete application and this form, understanding the requirements of Catalyst for Columbus to be a participant, and request that my child may be admitted into the program. *
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