ASP 2023

Coastal Arts Academy

Registration Form
Name

First NameLast Name
Birth Date

MonthDayYear
Gender
Care card #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number home
Please enter a valid phone number.
Phone Number cell
Please enter a valid phone number.
EMAIL ADDRESS
example@example.com
*Please list in the preferred order of contact**
school
transportation needed yes or no
Days attending

mondaytuesdaywednesdaythursdayfriday
FIRST CONTACT
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
SECOND CONTACT NAME
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
THIRD CONTACT NAME
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Persons Authorized to Pick Up Child:
Persons NOT Authorized to Pick Up Child
Any VISION conditions
(Please specify and indicate related treatment protocols)
Any HEARING conditions
(Please specify and indicate related treatment protocols)
Any ALLERGIES
ALLERGIES (Please specify and indicate related treatment protocols)
Authorizations/Acknowledgements:

, hereby authorize staff at Coastal Arts Academy to do the following (Please initial all that apply in the boxes below):
Initials*
DESCRIPTION OF ACTIVITY:
Photograph my child for identification in case of emergency (one for file and one for emergency contact card) 2.Take and post photographs for classroom use and documentation
Take and post photographs for use in Studio newsletters

Take and post photographs for use on website and social media pages

5.Take my child on local walking trips to nearby areas such as playgrounds, beaches, and walking trails
Signature

Clear
, hereby authorize staff at Coastal Arts Academy to obtain emergency medical/dental care and I understand that any/all ambulance costs incurred are the responsibility of the parents/guardians.
Signature

Clear
,hereby acknowledge that I have received a copy of the parent policy manual, that I have read and understood and agree to abide by the policies and procedures contained therein. I understand that failure to abide by the policies and procedures outlined in the parent policy manual may result in my child's dismissal from the program.
Signature

Clear
, hereby do not hold Coastal Arts Academy and staff responsible in case for loss of property, injury, or death.
Signature

Clear
,hereby authorize staff at Coastal Arts Academy / Jessa Pereira and its staff to pick up (from school) and transport my child to their studio 2790 cliffe ave Courtenay. I understand it is my responsibility as a parent to ensure the booster seat is not expired and for my child's proper weight and height. I also do not hold Coastal Arts Academy/ EDYC/ Jessa Pereira or Coastal Arts Academy staff responsible in case of injury or death.
Signature

Clear
Date

MonthDayYear
Date
Other Helpful Information: As no one knows your child better than you do, you have valuable insights that will help us provide care and learning experiences best suited to your child's interests, abilities, and needs. Please help us get to know your child and how to best comfort them. (likes, dislikes, major life events, comfort tools for your child etc. )
helpful information here
Should be Empty:

FIRST CONTACT

SECOND CONTACT NAME

THIRD CONTACT NAME

DESCRIPTION OF ACTIVITY: