STUDENT & PARENT INFORMATION For OutshineEDU

STUDENT & PARENT INFORMATION
PHONE: (858)-263-6148

EMAL: OUTSHINE@OUTSHINEEDU.COM

ADDRESS:9919 HIBERT ST SUITE B, SAN DIEGO, CA 92131
Student Name*
MaleFemale
Date of Birth*

MonthDayYear
Class Choice
Grade
Off school time
School Name
Note
Parent Name*
Parent Email*
example@example.com
Contact Phone#*
Format: (000) 000-0000.
Allergy or health concerns
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
PAYMENT POLICY
Withdrawals/Refund: If the student withdraws from the program, he/she has the option to receive either class credits towards future sessions (excluding any classes already taken at the time of withdraw), or he/she may obtain a tuition refund for the amount due at registration minus a $50 processing fee and any classes taken. Refund requests must be made in writing. No refunds are given for events that out of our control (flood, fire, electrical outage, etc No credits or refunds will be given for missing the class. Bounced Check: The drawer, who writes the check, will be responsible for the bank processing fee
INDEMNITY, RELEASE, WAIVER AND AUTHORIZATION FOR EMERGENCY MEDICAL CARE AGREEMENT
I request that the applicant listed above be permitted to participate in Outshine education center program(s I affirm that the applicant listed above is at program(s) he/she may receive necessary first aid, medical attention by a licensed physician or be admitted to a hospital in case of emergency. I will NOT hold Outshine education center, its officers, employees/staffs, agents, contractors and volunteers liable for medical aid rendered and will reimburse Outshine school. for medical or other expenses incurred in his/her care. I agree to release, indemnify, defend and hold Outshine Education Center, its officers, employees, agents, contractors and volunteers harmless and free from any and all liability resulting directly or indirectly from participation in the(se) program(s), including but not limit to liability for any and all demands, damages, claims, suits, liens and judgments, including costs and attorneys' fees, of whatever nature, for injury or death of any person, damage to property, or interference with the use of property, arising from or in connection with participation in the program(s I have carefully read this Indemnity, Release, Waiver and Authorization for Emergency Medical Care Agreement and fully understand its contents and understand that it shall be binding upon me, my heirs, successors and assigns. I am aware that this is a full release of liability and sign it of my own free will.

Photo and Video: I give permission for my /my child's (if student is under 18) photograph to be used by Outshine Education Center on its website and for any Outshine Education Center-related publicity, including print and broadcast media.
Parent or Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

STUDENT & PARENT INFORMATION

PAYMENT POLICY

INDEMNITY, RELEASE, WAIVER AND AUTHORIZATION FOR EMERGENCY MEDICAL CARE AGREEMENT