Summer Program Registration Form

Summer Program Registration

Great Work Montessori Program
Attendee Information

***Must have six student enrolled each week to run the program*** Cannot issue refund after June 21, 2025.
1st Child's Name

First NameLast Name
1st Child Birth Date

MonthDayYear
1st Child Grade
1st Child Gender

MaleFemale
What week(s) would you like your 1st child to attend?

Week 1- July 7- July 11- Montessori Week 1Week 2- July 14- July 18-Culinary ArtsWeek 3- July 21- July 25-Natural WondersWeek 4- July 28- August 1- Water WeekWeek 5- August 4- August 8-Montessori Week 2
2nd Child's Name

First NameLast Name
2nd Child Birth Date

MonthDayYear
2nd Child Grade
2nd Child Gender

MaleFemale
What week(s) would you like your 2nd child to attend?

Week 1- July 7- July 11- Montessori Week 1Week 2- July 14- July 18-Culinary ArtsWeek 3- July 21- July 25-Natural WondersWeek 4- July 28- August 1- Parks and RecreationWeek 5- August 4- August 8-Montessori Week 2
3rd Child's Name

First NameLast Name
3rd Child Birth Date

MonthDayYear
3rd Child Grade
3rd Child Gender

MaleFemale
What week(s) would you like your 3rd child to attend?

Week 1- July 7- July 11- Montessori Week 1Week 2- July 14- July 18-Culinary ArtsWeek 3- July 21- July 25-Natural WondersWeek 4- July 28- August 1- Parks and RecreationWeek 5- August 4- August 8-Montessori Week 2
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Mother's Name

First NameLast Name
Father's Name

First NameLast Name
Home Number
Mother's Mobile Number
Mother's E-mail
example@example.com
Father's Mobile Number
Father's E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Emergency Contact's Mobile Number
Relationship
Does the attendee have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the attendee prescribed an inhaler? If yes, please explain any instructions.
Informed Consent and Acknowledgement

I hereby approve of my child’s participation in any and all activities prepared by Great Work Montessori Program during the selected summer program(s). In exchange for the acceptance of said child’s candidacy by Great Work Montessori Program, I assume all risks and hazards incidental to the conduct of the activities and release, absolve and hold harmless Great Work Montessori Program and all its respective officers, agents, and representatives from any and all liability for injuries to the said child arising out of traveling to, participating in, or returning from selected program sessions.

In case of injury to said child, I hereby waive all claims against Great Work Montessori Program. Including all teachers, coaches and affiliates, all participants, sponsoring agencies, and, if applicable, owners and lessors of premises used to conduct the program and off-site properties to which we may visit. There is a risk of being injured that is inherent in activities during the program, including while on field trips. Depending on the location and activities, some of these injuries include but are not limited to, being bit by an animal, the risk of fractures, paralysis, or death.
Medical Release and Authorization

As Parent and/or Guardian of the named child(ren) listed above, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child(ren), in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, or x-ray examination, for the above-named child(ren). In the event of an emergency arising from a severe illness, the need for major surgery, or a significant accidental injury, I understand that the attending physician will make every attempt to contact the parents and emergency contact in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach a parent or named emergency contact as listed above.

Permission is also granted to the Great Work Montessori Program and its affiliates, including Directors, Teachers, Coaches, and Other Program Parents, to provide emergency treatment before the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered program weeks as chosen above.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of the life and limb of the named minor child, in my absence.

My Products

First Child

$325.00 Total Weeks
Item subtotal:$0.00

Second Child

$325.00 Total Weeks
Item subtotal:$0.00

Third Child

$325.00 Total Weeks
Item subtotal:$0.00

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Cash App Pay

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

MonthDayYear
Date
Signature

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Summer Program Registration

Attendee Information

Payment Methods