Student’s Name (first and last) *

Student’s Gender *

Student’s date of birth *

Student’s current grade *

Does your student have any allergies or medical conditions? Please list or type NONE below. *

Will your student ride the bus to the Learning Pod site or be dropped off/picked up? *

Parent/Guardian First and Last Name *

Parent/Guardian E-mail *

Parent/Guardian's Daytime Phone Number *

Student's Street Address-1 *

Student's Street Address-2

Student's City, State Zip Code *

Student's School *

Student's Teacher's Name *

Teacher's E-mail Address

Communication Platform (check all that apply)

Please provide a list of Virtual Learning Platforms Used (ie. Google Classroom)

Emergency Contact #1 - First and Last Name *

Emergency Contact #1 - Relationship to Student *

Emergency Contact #1 - Daytime Phone Number *

Emergency Contact #2 - First and Last Name *

Emergency Contact #2 - Relationship to Student *

Emergency Contact #2 - Daytime Phone Number *

How did you hear about the FCS Learning Pod? *

How will being at the pod help your student succeed? *

I would like to receive email updates Friendship Community Services news and events. *

IMPORTANT NOTICE: FCS asks that you be respectful of the State-Wide Mask Up Minnesota mandatory protocols set to ensure the safety of ALL Americans. Please note that any interaction with the general public poses a higher risk of being exposed to COVID-19. FCS is not responsible for the health and safety of participants. FCS asks that student and their parent/guardian follow the site’s safety policies, as well as local laws and restrictions. *

By completing this registration form for the Friendship Community Services Learning Pod, I understand that the scholar’s participation may be subject to a certain degree of risk. I have carefully considered any potential risk and, sign below, by doing so I hereby release Friendship Community Services, it’s parents, members, and employees, from any and all liability or claims awaiting initiation out of my child(ren)’s participation at Friendship Community Services Learning Pod. Release of liability shall extend to any and all claims involving or relating to property damage, bodily injury, or death suffered sustained by me or my child(ren). As a result of these unprecedented times, I agree to reinforce the importance of wearing a mask (mask guidance) at home as they are key for ALL schools to remain open, at this time. I further give the Friendship Community Services Learning Pod and its connecting sites permission to take and use, for promotional and educational purposes, across any and all mediums, any photograph or videotape of my child(ren) taken. If you do not consent to a media release, an opt-out form will be supplied on the day(s) surrounding that event. *

Parent/Guardian (Please type name below as your electronic signature to register your student for the FCS Virtual Learning Center) *