RPEP VIRTUAL OR HOME-SCHOOL OPTION

ENROLLMENT FORM

FOR

VIRTUAL & HOMESCHOOL OPTIONS

SY 2021-2022

* Please complete one form per student

Registration Fees will be paid through Square and must be completed in order to complete registration process online. YOU DO NOT need to have a Square account to use this system and may use credit card or debit card. If you do not have a Square account you may sign in as a "guest".

Entrance Date *

Date

Student Information:

First name *

Last name *

M.I. *

Male or female? *

Female Male

MEALS REQUIRED

YES BREAKFAST ONLY LUNCH ONLY PM SNACK ONLY BREAKFAST, LUNCH & PM SNACK NO

Street address *

Street address line 2

City *

State *

Zip code *

Who does the child live with? *

Name of Public or Private School child # 1 attends, if any *

Parent's Information:

Parent's/Guardian's name (MOTHER) *

Parent's/Guardian's name (FATHER) *

Home/Cellular number *

Work number *

Place of work *

Address *

Street Address

Street Address Line 2

City State

Zip Code

Address *

Street Address

Street Address Line 2

City State

Zip Code

Email address *

example@example.com

Emergency Contact 1:
In the event of an emergency, please contact:

First name *

Last name *

Primary phone number *

Secondary phone number

Emergency Contact 2:
In the event of an emergency, please contact:

First name *

Last name *

Primary phone number *

Secondary phone number

Other people authorized to pick up your child:

First name *

Last name *

First name *

Last name *

First name *

Last name *

Medical information:

Doctor *

Doctor's phone number *

Dentist *

Dentist's phone number *

Preferred hospital *

Is the child covered by medical insurance? *

YES NO

Name of Insurance Company (enter none if no insurance): *

Policy Number (enter none if no insurance): *

Please list any of the following: Current medications, medication allergies, food allergies, special needs/accommodations or chronic health concerns. *

Electronic Signature: By entering my name below, I accept the above conditions and releases. (You must be 18 years old or over to sign below.)I, as the registered am 18 or over, or I am a parent or legal guardian of the registered who is currently under the age of 18, grant permission for the registered camper to attend PHOENIX ACADEMY OF SCHOLARS and consent to its Discipline Policy and also do hereby release PHOENIX ACADEMY OF SCHOLARS from any and all liability or responsibility due to any injury that he/she/I may incur as the result of, or arising in any way from participation in activities at or under the direction of PHOENIX ACADEMY OF SCHOLARS. I am fully aware and consent to accept these risks and voluntarily agree to allow his/her participation in activities. If I cannot be consulted in an emergency, I hereby give permission to the physician selected by a representative of PHOENIX ACADEMY OF SCHOLARS to hospitalize, secure treatment for, and to order injections, anesthesia, and/or surgery for the person named above. I understand that PHOENIX ACADEMY OF SCHOLARS only carries secondary insurance and that I will take primary responsibility for any fees or charges at any clinic, facility, or hospital arising from treatment of injury or illness. I furthermore understand PHOENIX ACADEMY OF SCHOLARS often takes photographs or videos of participants during its activities or events. I grant permission without compensation that these photographs or videos may be used in publications, presentations, websites or promotion of PHOENIX ACADEMY OF SCHOLARS. Rising Phoenix will not identify me or my child by name, or release any other personal information without additional written permission from me. *

First Name Last Name

Current Date: *

Date

Which grade level requires Virtual Learning?

K-5 Elementary 6-8 Middle 9-12 High School

Which grade level requires Accredited Homeschool Learning?

K-5 Elementary 6-8 Middle 9-12 High School

For Security, type the message seen below: *

An 80% refund of is made if written notice is given to RPEP two weeks prior to your childs first day of services. A 50% refund is made if written notice is given to RPEP within 2 weeks of the start of services. No refund will be made once the services start. Canceled online store deposits and merchandise purchases will be refunded at 95% to compensate for fees RPEP has to pay.
All refunds are processed within 30 Days of written notice.

Upon completion of filling in all areas of form, click "Submit". You will then be taken to Square where you will pay and registration process will be completed. Only one camper may be registered at a time. You may click "Print Form" to print a copy of this form. Do you have questions or need help with online registration? Email us at info@risingphoenixinc.org. *Please allow 48 hours for a response.*

Withdrawal Date (DO NOT COMPLETE, AUTHORIZED USE ONLY)

Date

My Products

RPEP T-Shirt $ 10.00

RPEP Tote Bag $ 20.00

RPEP Water Bottle $ 10.00

K-12 Home-school Instructional Time ONLY $ 80.00

Monday-Friday 7:30A-1:30P Weekly Rate

K-12 Virtual Learning Assistance Time ONLY $ 80.00

M-F Hours vary depending on educational level Weekly Rate

K-12 Weekly After School Enrichment ONLY $ 70.00

M-F 1: 00P-6: 30P Weekly rate

K-12 Weekly Academics Plus Enrichment $ 120.00

M-F 7:30A-6:30P

Reserve My Spot $ 50.00

Non-Refundable, : paid amount will be applied to the full payment

Enter coupon

Total $ 0.00

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