2025 Fall Registration Form

Fall Registration 2025
Student Information
Child's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
Age
Grade Completed
Gender

MaleFemale
Parent/Guardian Information
Mother's Information

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Father's Information

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

First NameLast Name
Relationship
Phone Number
Second Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Does your child have any prescribed medications, EpiPen or inhaler? If yes, please explain any instructions.

Select Days Requested ( Please note the 2's class is only offered Monday, Wednesday and Friday)

5 days (Monday - Friday)4 days (Monday - Thursday)3 days (Monday, Wednesday, Friday)2 days (Tuesday, Thursday)Other
Payments can be made via PayPal or Venmo or you may mail a check to:

Live & Learn Academy

804 Fieldstone Road

Mooresville, NC 28115

Paypal: LiveLearnAcademy@hotmail.com

Venmo: @LiveLearnAcademy

* If enrolling in half day school age camp, select preschool rate below
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Live & Learn Academy during the selected school year. In exchange for the acceptance of said child’s candidacy by Live & Learn Academy, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Live & Learn Academy and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected school sessions.

In case of injury to said child, I hereby waive all claims against Live & Learn Academy including all counselors and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.
Medical Release and Authorization

As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, 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 also granted to Live & Learn Academy and its affiliates including Owners, Directors and Counselors to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered school session.

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 life and limb of the named minor child, in my absence.
Payments and Refunds

I understand that my child's registation in preschool program at Live & Learn Academy is not finalized without both the registration form and payment completed. Please do not submit one without the other! We do not issue refunds once submitted.
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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Fall Registration 2025

Student Information