Registration Form

Student Name*

First NameLast Name

Birth Date*

Date

Grade Level

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent Phone Number*

Parent Email E-mail*

example@example.com

Emergency Contact*

Emergency Contact Phone Number*

Please enter a valid phone number.

Classes*

How did you hear about us?*

Additional information about your child, including allergies, medical issues, or disabilities:

Liability Release

We assume full responsibility for all risk of injury or loss that may result from participation in any current and future classes at The Bentley Center and agree to hold harmless, release, and forever discharge The Bentley Center, its contributors, and their respective officers, directors, agents, and employees. We agree to waive any and all claims and demands whatsoever which we, our child, or any third party may now or hereafter have against any party of The Bentley Center by reason of accident, illness, injury, or death to persons, or damage to, or loss of any property, arising or resulting directly or indirectly from our child’s participation in this Program. We have read and understood the above statements, and we hereby agree to all of the foregoing terms and conditions.

Student Code of Conduct

▪ to respect individuals of different races, cultures, religions, genders, disabilities, and national origins
▪ to behave in a friendly, cooperative, and responsible manner toward all persons in our classes
▪ to be responsible for one’s own actions
▪ to behave in an honest and trustworthy manner
▪ to adhere to all rules and directions given by staff

PROHIBITED ITEMS

The following is a list of items students are prohibited from bringing to the site:

▪ weapons of any kind or any toys that look like weapons
▪ any flame-producing device (including matches, lighters, and firecrackers)
▪ pets of any kind
▪ all electronic devices except those deemed necessary by instructors

DISMISSAL POLICY

We cannot accommodate students who are unable to live up to the expectations set forth in the Code of Conduct. Violation of any of the policies may result in immediate dismissal. No refunds will be made to students dismissed from The Bentley Center.

In addition, students may be dismissed from The Bentley Center for the following reasons:

▪ vandalism or theft
▪ engaging in disruptive behavior
▪ leaving the classroom unaccompanied by a staff member
▪ being in restricted areas unaccompanied by a staff member
▪ any violation of the safety or well-being of any person

We have read the Code of Conduct policies. We understand our responsibility to abide by the program requirements outlined above, and that failure to comply may result in suspension and/or expulsion from the program.

Student Name

Parent/Guardian Signature