After-School Program 2021 Enrollment Form

Saint Paul's Choir School After-School Program Sign-Up 2021-22

29 Mount Auburn Street, Cambridge MA 02138 (617) 868-8658
PROGRAMMING SELECTION:

Select your days and programs below.
After-School programs to be enrolled:

Monday 3:15-5:00, Stock Market Club Monday & Friday 3:15-5:00, Mandarin Tuesday 3:15-5:00, Frassati Society Tuesday 3:15-5:00, Visual Arts Wednesday 3:15-5:00, French Lab Wednesday 3:15-5:00, Chess Club
CHILD INFORMATION:
Child Name *

First Name Last Name
Birth Date *

Month Day Year
Grade *
Please type the grade your child entered in September 2021
Name of Current School *
PARENT/GUARDIAN INFORMATION:
Parent/Guardian 1 Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Alternate/Work Phone Number

Area Code Phone Number
E-mail *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Parent/Guardian 2 Name

First Name Last Name
Phone Number

Area Code Phone Number
E-mail
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
MEDICAL INFORMATION
Physician Name *

First Name Last Name
Physician Phone Number *

Area Code Phone Number
Allergies *
If none, type NO.
Allergy Medications & Plan *
Please indicate here which medications your child may require for his or her allergies. If your son or daughter has a prescription for an Epi-Pen or similar, we will require that one be kept onsite. Further, please advise if you have a doctor's written allergy plan; if so, we will require a copy. If none of this applies, type NO.
Medical Concerns (Non Allergy) *
Please include necessary medications and/or other health concerns that we should be aware of in providing care for your child. If none, type NO.
Insurance Provider *
Include Group Number above, if applicable
Policy Information *

Policy Number Provider Phone Number
Primary Emergency Contact *

Name Phone Number
Secondary Emergency Contact *

Name Phone Number
Medical Care Release:

I hereby delegate authority to the Directors of the Saint Paul's Choir School Summer Program to arrange whatever medical treatment they deem necessary for my child during his/her program day (from arrival until pick-up, August 17-21, 2019). Please type your name below as your digital signature.
Medical Care Release Signature *

First Name Last Name
Participation and Liability Waiver:

I hereby give permission for our son/daughter to participate in all activities conducted by SPCS. We agree to hold the directors and staff harmless from any liability to anyone on account of any injuries to our son. I understand that SPCS cannot be responsible for lost or broken items. I understand my son/daughter will comply with all program policies and procedures. I also understand, and will comply with, all cancellation policies and procedures. Please type your name below as your digital signature.
Participation and Liability Waiver Signature *

First Name Last Name
Photo Release:

St. Paul’s Choir School has my permission for the child named above to be photographed and/or videotaped. I realize that the photo may be published in the newspaper, a magazine, the school website, television or other publications. The video may be used for informational or educational purposes to promote the mission of The St. Paul’s Choir School. Please type your name below as your digital signature.
Photo Release Signature *

First Name Last Name
Contact Us:

(617) 868-8658 / admissions@saintpaulschoirschool.us / pmoran@saintpaulschoirschool.us
Should be Empty:

Saint Paul's Choir School After-School Program Sign-Up 2021-22

PROGRAMMING SELECTION:

CHILD INFORMATION:

PARENT/GUARDIAN INFORMATION:

MEDICAL INFORMATION

Medical Care Release:

Participation and Liability Waiver:

Photo Release:

Contact Us: