Summer Program Enrollment Form

Life skills 101 w. Parris Watson M.Ed

Summer program
STUDENT INFORMATION:

Please note that this event is a youth event only for ages 13-18. Drop of is at 3:45pm Pick up is at 6:30pm. July 18th* only Pick up is at 5:30pm*
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade current as of June*
PARENT/GUARDIAN INFORMATION:

Emergency contact
Parent/Guardian Name *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Relationship*
Emergency Contact *

First NameLast Name
Phone Number*

Area CodePhone Number
MEDICAL INFORMATION

Dietary restrictions, allergies, chronic illness, medical conditions?
If yes to any, please list them.
What experience does your child have when it pertains to life skills?

Cooking, budgeting, taking public transportation?
Please indicate which area your child falls under.

My child has a great deal of experience with lifeskills, but more support never hurt.My child has some experience with life skills, but needs more supportMy child has little to none experience with life skills, and needs extra support.
Summer Program Wavier

I, acknowledge that participation in Life skills 101 Summer Program, involves certain risks. I understand and agree to release Notable Minds, its organizers, volunteers, and staff from any liability for injury, loss, or damage arising from my participation in the camp activities.
I consentI do not consent
Photo & Video Release

I hereby grant Notable Minds permission to use my photograph and/or video image in any and all of its publications, including web-based publications, without payment or other consideration. I understand that my image may be used on social media to bring awareness to the program only.
I consentI do not consent
Acknowledgement/Signature

I have read and agree to abide by the terms and conditions set forth by Notable Minds. I also understand that I'm responsible for dropping off and picking up my child at the times listed on the flyer.
I agree
Should be Empty:

Life skills 101 w. Parris Watson M.Ed

STUDENT INFORMATION:

PARENT/GUARDIAN INFORMATION:

MEDICAL INFORMATION

What experience does your child have when it pertains to life skills?

Summer Program Wavier

Photo & Video Release

Acknowledgement/Signature