Natomas Homeschool Alliance Enrollment Application 2024/2025

Parent/Guardian Information

Parent Name (Primary Contact)*

First NameLast Name

Cell Number*

Area CodePhone Number

E-mail*

Parent Name (Secondary Contact)

First NameLast Name

Cell Number

Area CodePhone Number

E-mail

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Number

Area CodePhone Number

Number of Years Homeschooling:

Homeschool Affiliation*

Emergency Information

Emergency Contact (not listed above)*

First NameLast Name

Emergency Contact Phone*

Area CodePhone Number

Family Doctor

Family Doctor Number

Area CodePhone Number

Health Insurance Company

Policy #

Desired Hospital in the event of an emergency

Child Registration Information (first child)

Child's Name*

First NameLast Name

Date of Birth*

MonthDayYear

Grade (as of September 1)*

Allergies/Medical Information/Learning Differences/Other - if none use N/A*

Add another child*

Child Registration Information (second child)

Child's Name

First NameLast Name

Date of Birth

MonthDayYear

Grade (as of September 1)

Allergies/Medical Information/Learning Differences/Other

Add another child

Child Registration Information (third child)

Child's Name

First NameLast Name

Date of Birth

MonthDayYear

Grade (as of September 1)

Allergies/Medical Information/Learning Differences/Other

Add another child

Child Registration Information (fourth child)

Child's Name

First NameLast Name

Date of Birth

MonthDayYear

Grade (as of September 1)

Allergies/Medical Information/Learning Differences/Other

Add another child

Child Registration Information (fifth child)

Child's Name

First NameLast Name

Date of Birth

MonthDayYear

Grade (as of September 1)

Allergies/Medical Information/Learning Differences/Other

PLEASE NOTE: For severe allergies, chronic medical conditions, or behavioral challenges, please contact Tiffany Millen with additional information at tiffany.millen@hackschooling.net.

Drop off/Pick up Policy TK-2nd (3rd) River City Baptist Campus Only (Click to acknowledge)*

I understand that children must be dropped off and picked up at the classroom by an adult. Children should not be dropped off in the parking lot.

IN CONSIDERATION of being a participant in the Natomas Homeschool Alliance (hereafter “NHA”) and being permitted to utilize the facilities of The Crossing Church (hereafter “The Crossing”), Iron Mile Gym (hereafter “Iron Mile”), River City Baptist Church (hereafter “RCBC”), The Cornerstone Bible Church (hereafter “TCBC”) or any other facility graciously provided for use by the NHA, I, the undersigned, intending to be legally bound for my family, do hereby:

(Click to agree)*

Acknowledge that my family’s participation in NHA and my family’s utilization of The Crossing, Iron Mile, RCBC, TCBC or other facility could expose my family to a possible risk of personal injury and I assume all risks inherent in such participation and/or utilization.

(Click to agree)*

Release and agree to indemnify both NHA, The Crossing, Iron Mile, RCBC, TCBC and any other facility utilized by NHA, which includes any NHA member, board member, instructor, vendor, Iron Mile owners and employees, and any of The Crossing’s officers, elders, staff members, and employees, from any and all claims by or against my family for property damage, personal injury, and/or claims arising from my family’s participation and/or utilization, including claims that are known or unknown, foreseen or unforeseen, future or contingent;

(Click to agree)*

Agree that my family shall not now or at any time in the future, directly or indirectly, commence or prosecute any action suit, or other legal proceeding against either NHA, The Crossing, Iron Mile, RCBC, TCBC or any facility used by NHA arising out of, relating to, or in connection with the actions, causes of action, claims and demands hereby waived, released or discharged by me;

(Click to agree)*

Agree that in the event that my child is injured while under the care of the Natomas Homeschool Alliance and requires medical attention, I hereby consent to and will be responsible for any reasonable medical treatment as deemed necessary.

(Click to agree)*

Attest that I am of legal age to execute this form as a binding legal document in accordance with its intention.

(Click to agree)*

In addition, I attest that I have read and agree to abide by the Community Values Statement found on the NHA website.

(Click to agree)*

I understand that NHA may, at the director’s/instructor’s discretion, release academic information to representatives of charter school entities responsible for payment of tuition.

(Click to agree)*

By signing this agreement, I acknowledge that I am aware of the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 at NHA, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I voluntarily choose to assume all of the foregoing risks and accept sole responsibility for any injury, illness, permanent disability, or death related to COVID-19 arising from or in connection with my presence at the NHA. I hereby release and hold harmless NHA, its facilities, employees, agents, directors, officers and representatives and other participants from and against all liabilities.

Signature*

Enrollment Application 2024/2025

Please include information for all children who will be participating in NHA programs this year.

Waiver and Release of Liability