Enroll

Full name of student

First NameLast Name

Date of Birth

MonthDayYear

Rising Grade (Grade Going Into)

Grade Level Completed

Gender

MaleFemaleOther

T-SHIRT Size

Military dependent?

YesNo

How does your child perform in mathematics?

On grade levelBelow grade levelAdvanced

How does your child perform in language arts?

On grade levelBelow grade levelAdvanced

Name of Parent/Legal guardian

First NameLast Name

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact 1

Name and Phone Number

Emergency Contact 2

Name and Phone Number

Authorized Pick Up Person 1

Name and Phone Number

Car Type

Make, Model, Color

Authorized Pick Up Person 2

Name and Phone Number

Car Type

Make, Model, Color

I give permission for my child to be photographed. I understand the photographs are the property of Achieve Academy and may be used in any manner including but not limited to promotional (media,flyers,banners,etc.) related material to Achieve Academy Inc

Immunization Records

Please upload your child's most recent immunization form.

Please share any important health information, food allergies, or medical conditions we should be aware of. If your child has special needs or requires classroom accommodations (including behavioral or learning support), let us know so we can best support them.Note: Food items may occasionally be used during activities. If your child has any food-related allergies or dietary restrictions, please list them below.

List all present medications.

Should your child be restricted from any activity?

YesNo

In the event my child suffers an illness or accident requiring medical treatment while involved in Achieve Academy, I hereby give permission for any necessary hospitalization, medication, or surgery on recommendation of medical personnel, in which case all such expenses shall be paid by me. In the event of sickness or accident, I waive all claims against Achieve Academy, its members, officers, agents, employees, and volunteers that may arise from participants in the activities of Achieve Academy. The undersigned hereby acknowledges that they have read, understand, and agree to all documents related to Achieve Academy, including the School Handbook. The undersigned hereby waives all claims against Achieve Academy and its employees or volunteer workers for injury,accident or illness by reason of participation in the Achieve Academy program.*

Registration & Cancellation Policy

A non-refundable $65 registration fee is required to reserve your child’s spot. Payment can be made via Cash App to $AchieveWR, in cash, or by check payable to Achieve Academy. This fee includes a camp shirt.

Please note: All sales are final. Cancellations must be submitted in writing 30 days in advance to tarapvel@achieveacademy.education, along with reasonable verification.

A 25% cancellation fee will apply if canceled more than 30 days before the program start date.

A 50% cancellation fee will apply if canceled within 30 days of the program start date.

No refunds or transfers will be granted within five (5) business days of the start of the program or if your child does not attend.

By signing below, I acknowledge that I have read, understand, and agree to the registration and cancellation policy stated above. I understand that the registration fee is non-refundable and required to reserve my child’s spot.*

Date*

MonthDayYear

Discount Code

COVENANT COMMUNITY CONNECTION BIBLE CHURCH

Accident Waiver and Release of Liability Form

I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING AND/OR

VOLUNTEERING IN THIS ACTIVITY OR EVENT, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without

| certify that I am physically fit, have sufficiently prepared or trained for participation in the activity or event, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this activity or event. I acknowledge that this Accident Waiver and Release of Liability Form will be used by the event holders, sponsors, and organizers of the activity or event in which I may participate, and that it will govern my actions and responsibilities at said activity or

In consideration of my application and permitting me to participate in this event, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this event, Covenant Community Connection Bible Church (C3 Bible Church) and/or their directors, officers, employees, volunteers, representatives, and agents, the activity or event holders, activity or event sponsors, activity or event volunteers; (B) I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity or event, whether caused by the negligence of release or otherwise.

I acknowledge that the C3 Bible Church and their staff, volunteers, representatives, and agents are NOT responsible for errors, omissions, acts, or failures to act of any party or entity conducting a specific event or activity on behalf of C3 Bible Church. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity or event. The accident waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS

CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.

Is your application dependent on receiving Promise Scholarship funds?*

YesNo

Print Child's Name

Age

PARENT/GUARDIAN WAIVER FOR MINORS (Under 18 years old) The undersigned parent and natural guardian does hereby represent that he/she is, in fact, acting in such capacity, has consented to his/her child or ward's participation in the activity or event, and has agreed individually and on behalf of the child or ward, to the terms of the accident waiver and release of liability set forth above. The undersigned parent or guardian further agrees to save and hold harmless and indemnify each and all of the parties referred to above from all liability, loss, cost, claim, or damage whatsoever which may be imposed upon said parties because of any defect in or lack of such capacity to so act and release said parties on behalf of the minor and the parents or legal guardian.

Print Parent Name

Signature

Date

Summer Camp Enrollment Form