Enrollment Form

School (after-school and summer camp)

Start Date

Date

Student's Name*

First NameLast Name

Nickname

Grade*

Gender*

MaleFemaleOther

Social Security #

Special Accommodations & Allergies

Student's Name

First NameLast Name

Nickname

Grade

Gender

MaleFemaleOther

Social Security #

Special Accommodations & Allergies

Student's Name

First NameLast Name

Nickname

Grade

Gender

MaleFemaleOther

Social Security #

Special Accommodations & Allergies

Parent Guardian 1*

First NameLast Name

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Daytime Phone

Area CodePhone Number

Evening Phone

Area CodePhone Number

Cell Phone*

Area CodePhone Number

E-mail Address*

Parent Guardian 2

First NameLast Name

Daytime Phone

Area CodePhone Number

Cell Phone*

Area CodePhone Number

Does your child have health insurance?

YesNo

Insurace Company

Policy #

Group

Family Doctor

Phone Number

Area CodePhone Number

In case of emergency and the parent or caregiver cannot be reached, please notify:

Name*

Relation*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Daytime Phone

Area CodePhone Number

Evening Phone

Area CodePhone Number

Cell Phone*

Area CodePhone Number

Please list any current medications, medical conditions, recent injuries, and food or drug allergies:

1. Name*

First NameLast Name

Telephone Number*

Area CodePhone Number

2. Name*

First NameLast Name

Telephone Number*

Area CodePhone Number

3. Name*

First NameLast Name

Telephone Number*

Area CodePhone Number

Parents and/or legal guardians, please read carefully, sign, and return this form to the Barron Academy. Please initial at the end of each section. By initialing by each section, you are stating that you agree with what was stated. A parent or legal guardian signature on this form is required to participate in any Barron Academy Program.

I authorize the Barron Academy to arrange transportation in case of an accident or acute illness of the participant. In the event it is not possible to receive instruction for the participant’s care, consent is given to any licensed physician for treatment. I allow the physician to administer medication and to perform necessary treatment for the preservation of the participant’s health and well-being. I understand that any cost incurred for the treatment of sudden illness or accident shall be paid by me. This authorization and consent for treatment are given to the Barron Academy in conjunction with any authorized event.

Initials*

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Barron Academy, LLC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that Barron Academy, LLC can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, center staff, and other students and their families.

I voluntarily seek services provided by Barron Academy, LLC, and acknowledge that I am increasing my risk of exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my tutoring session.

I attest that:
* I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
* I have not traveled internationally within the last 14 days.
* I have not traveled to a highly impacted area within the United States of America in the last 14 days.
* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non-contagious by state or local public health authorities.
* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.

I hereby release and agree to hold Barron Academy, LLC harmless from and waive on behalf of myself, my child, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses, and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the center, or that may otherwise arise in any way in connection with any services received from Barron Academy, LLC. I understand that this release discharges Barron Academy, LLC from any liability or claim that I, my child, or any personal representatives may have against this company with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Barron Academy, LLC. This liability waiver and release extends to the center together with all owners, partners, and employees.

Initials*

In consideration of being allowed participant privileges in any program of Barron Academy, I hereby assume full responsibility for any risk of bodily injury, death, or property damage and/or while using the premises or any facilities or equipment hereon. I further agree to hold harmless the Barron Academy, their partners, directors, officers, employees, agents, and volunteers from any and all claims that may result from any action for damages, including but not limited, to such claims that may result from injury or death, accident or otherwise, during or arising in any way from said activity. I acknowledge that this General Release of Liability of Barron Academy and its partners is binding on me and not my heirs, personal representatives, successors, and assigns.

Initials*

I hereby consent to the use of my child’s photo/my child’s name, likeness, and speech in an audiotape, videotape, film, or photograph made in any Barron Academy activity for the business or publicity purposes of the Barron Academy and its partners. I understand that any participation offers no remuneration and that my/my child’s name, likeness, and speech may be edited, produced, recorded for duplication and distribution throughout the United States and abroad.

I expressly release the Barron Academy, its licensees, assignees, affiliates, and successors from any privacy, defamation, or other claims have arising out of the broadcast, exhibition, publication, or promotion of this program.

Initials*

Parent/Legal Guardian *

First NameLast Name

Date*

TUTORING ONLY: I am enrolling my child for one-on-one tutoring. My tutoring location preference is:

In-PersonOnline

1. Why are you requesting tutoring for your child at this time?

2. How long (years or months) and what grades has your child had difficulty in the subject(s) you are requesting tutoring?

3. What kinds of tutoring/support help have you provided at home for your child?

PLEASE NOTE:

Tutoring requests are granted by Barron Academy for students who attend outside the community, after all the services and resources of the school have been thoroughly exhausted, i.e. lunchtime and after school tutoring.

The following factors should also be considered by parents when assessing the reasons for requesting extra help for their child:

Does your child have established work and study habits?
Does your child spend a lot of time watching television and playing electronic games?
Does your child spend a lot of time on organized sports teams and recreation?
Does your child have access to reference materials and equipment?

Enrollment Form

Emergency Contact

Dismissal/Sign Out

Parent/Guardian Release

For Emergency Treatment

COVID WAIVER

General Release of Liability

Media Release

THIS SECTION IS FOR INDIVIDUAL TUTORING STUDENTS ONLY