DESOTO HOUSE OF PEACE ONLINE SCHOOL REGISTRATION FORM

DESOTO HOUSE OF PEACE ONLINE SCHOOL

Registration Form
Child Name*

First NameLast Name
Age*
Gender*
Date of Birth*

MonthDayYear
Date
Current Grade Level *
Grade level on next school year*
Home Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number*
Please enter a valid phone number.
Parent / Guardian Information
Name*

First NameLast Name
Relationship to Child*
Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
Please enter a valid phone number.
Email*
example@example.com
Does the child have any allergies? If yes, please list them below:
Does the child currently taking medications? If yes, please list them below and provide the reason:
Does the participant have any medical condition that we should be aware of? If yes, please explain below:
Upload Student's Birth Certificate

Cancelof
Upload Academic Records

Cancelof
Upload ID of Parent and Student

Cancelof
Registration Fee:
prevnext( X )
One-Time Registration and Supply Fee:(This fee is non-refundable and covers administrative processing, curriculum materials, and essential supplies for the academic year.)
$200.00 Quantity



One-Time Registration and Supply Fee before June 1st:(This fee is non-refundable and covers administrative processing, curriculum materials, and essential supplies for the academic year.)
$100.00 Quantity



K-12 Grade (First child)
$550.00 Quantity



K-12 Grade (Second child):
$525.00 Quantity



K-12 Grade ( Third child and beyond):
$500.00 Quantity



Total

$0.00
Upload Proof of Texas Residency

Cancelof

Terms and Conditions
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by DeSoto House of Peace during the selected school. In exchange for the acceptance of said child’s candidacy by DeSoto House of Peace ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless DeSoto House of Peace . 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 camp sessions.

In case of injury to said child, I hereby waive all claims against DeSoto House of Peace . including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Medical Release and Authorization

As Parent and/or Guardian of the named student, 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 hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the DeSoto House of Peace . and its affiliates including Directors, Teachers, Coaches, and Team Parents 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 season.

I hereby authorize DeSoto House of Peace, volunteer personnel to conduct first aid, and medical care in the event of an emergency situation. I agreed to pay for all the medical care expenses and costs in a given situation that medical care is needed.

I release the organizers from any liabilities that might happen during the activity and hold them harmless in the event of damages, injuries, or accidents.

I confirm that all information in this form is accurate and true to the best of my knowledge.

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.
Do you allow DeSoto House of Peace to take photos or videos during the activities of your child for advertising and marketing purposes that will be posted on social media?*

YesNo
Parent/Guardian Signature*

Powered by Jotform SignClear
Date Signed*

MonthDayYear
Date
Should be Empty:

DESOTO HOUSE OF PEACE ONLINE SCHOOL

Parent / Guardian Information

Terms and Conditions