Bodhi Academy - iMAP Registration
Please complete all requested information so that we can properly assist your child. If you have more than one child to register, please register them individually.
STUDENT INFORMATION SECTION
Student's First Name: *
Your answer
Student's Middle Name: *
Put "None" if this is no middle name
Your answer
Student's Last Name: *
Your answer
Date of Birth *
mm/dd/yyyy
Your answer
School Name *
Your answer
School District *
Grade (1st - 8th; please contact us if your child is a higher grade range) *
Your answer
On what day of the week and time does your child leave early from school? *
Please write in day and time your child leaves early
Your answer
How many days a week will your child participate in iMAP? *
Required
Will your child need to be picked up from school and driven to our center? *
(if yes, please provide school address in the "Other" field below)
Required
Does your child have an IEP? (mark No if you do not know what this is)
Is there special condition, medically or psychologically, that we should be aware of in order for us to better support your child? *
Your answer
Is there anything else you would like us to know about your child in order for us to better support him/her? *
Your answer
Does your child have any allergies to food or medicine? (if yes, please list) *
Your answer
PARENT/LEGAL GUARDIAN INFORMATION SECTION
Full Name of Parent/Guardian 1 *
First, Last, Middle Initial
Your answer
PIN for Parent/Guardian 1 (4-digit) *
To help identify yourself on the phone
Your answer
Phone number 1: *
Your answer
Full Name of Parent/Guardian 2 *
First, Last, Middle Initial
Your answer
PIN for Parent/Guardian 2 *
To help identify yourself on the phone
Your answer
Phone number 2: *
Your answer
Home Address *
Full address for mailing
Your answer
Email: *
Your answer
Please re-enter your email: *
Please use email address that you check most often for our frequent communications
Your answer
Emergency Contact: Name and Phone number of you or your closest relative *
Please list the one who will be available during the time your child is in our care.
Your answer
Emergency Contact: Name and Phone number of your Family Doctor *
In the case you weren't available during the time your child is in our care.
Your answer
Please list the names and phone numbers of additional people who you authorize to pick up your child from the center. Any changes of adding or deleting names need to be submitted in writing to us. *
Name/Relationship/Phone. Write "NONE" if only parents are authorized to pick up.
Your answer
By typing in my full name in the box below, I certify all the information provided above are correct and agree to enroll my child into the programs indicated above. I recognize the risks of illness and injury inherent in any program and am participating in the express agreement and understanding that I am hereby waiving and releasing LIABILITY, INDEMNIFY and HOLD HARMLESS the instructors, volunteer staff, employees of the Bodhi Academy (BA), an official subsidiary of Bodhi Youth of America (BYA), and its Board of Directors, BYA partners and affiliations, and their officers, employees and volunteers from and against all claims, costs, liabilities, expenses or judgments arising out of participation in the program. I hereby agree to the aforementioned statement and release BA and BYA and its associates of any financial and/or medical obligation which might be incurred. This electronic typing signature/handwritten signature also allows videos and pictures to be taken of my child for student protection and promotion of BA and BYA programs. *
Your answer
Date of your signature submission *
MM
/
DD
/
YYYY
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This form was created inside of Bodhi Youth of America.