LEI Spring Registration

Parent/Guardian and Emergency Contact Information

Please provide at least one parent or guardian contact.
Parent/Guardian Full Name*

First NameLast Name
Parent/Guardian Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Relationship to Child*
Parent/Guardian Email*
example@example.com
Second Parent/Guardian Full Name

First NameLast Name
Second Parent/Guardian Relationship to Child
Second Parent/Guardian Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Second Parent/Guardian Email
example@example.com
Alternate Emergency Contact:

First NameLast Name
Alternate Emergency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Emergency Contact Relationship to Student:

Learning & Medical Concerns
Please describe any special learning concerns you might have for your child:
Please describe any medical or health concerns (i.e. allergies, asthma, diabetes, etc.):
YesNo
Lake Erie Ink will always call 911 in the event of a medical emergency, but we will alert first responders and medical personnel if your child does not have consent for medical treatment.

Pickup Information
YesNo
If anyone other than the parents/guardians listed above will be picking up your child, please enter their full names and phone numbers below:
Liability Release: I understand and agree that Lake Erie Ink: A Writing Space for Youth (hereafter “LEI”) is not responsible for supervising my child or for my child’s safety after the end of the program, and that neither LEI nor any of its staff members is liable for any physical or emotional harm to my child, caused by my child’s negligence or by the negligence, intentional act or criminal act of a third party, nor for any property or damage or loss caused by my child.*

I understand

Permissions
Student email which will be used during virtual programs.
example@example.com
YesNo
YesNo
YesNo
Freedom of Expression Policy: Lake Erie Ink believes in freedom of speech and respects the right of all participants to express themselves honestly and creatively. However, we reserve the right to contact parents/guardians/school authorities if we feel the content of a participants work suggests possible harm to self or others. I have read and consent to the Lake Erie Ink Freedom of Expression policy:*

YesNo
Parent/Guardian Signature*

Clear
Student Signature:*

Clear

Register for Spring 2026!

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