Student Enrollment & Release Form: SPROUTS

Student Enrollment & Release Form

Assalamu Alaikum Wa Rahmatullah. Please read the form carefully and fill up. For any question please contact at :+1-682-233-1788
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*
Is the Child Potty Trained?*
Parent's or Guardian's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Emergency Contact*

First NameLast Name
Phone Number*

PROGRAM DETAILS
Which days will your child attend Sprouts:*

4 pm - 7 pm: Monday, Wednesday, Friday - $300 a month4 pm - 7 pm: Tuesday, Thursday - $250 a month
I understand tuition is an annual fee and can either be paid one of two ways, 1) in full or 2) making nine monthly payments (for full school year). I choose to meet my tuition obligations by using the payment plan I have checked:*

In FullMonthly Payments
You must give at least 30 days notice before changes to your child's schedule that affect tuitionare put into effect. You will be responsible for tuition during that month.*

I ACCEPT
Each month's tuition is due by the third day of that month and must be paid by Zelle or cash. PAYMENTS MADE AFTER THE FIFTH DAY OF THE MONTH WILL BEASSESSED A $5 PER DAY LATE CHARGE UNTIL PAID.*

I ACCEPT

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING

ACKNOWLEDGEMENT AND RELEASE AUTHORIZATION FOR MEDICAL TREATMENT:
I am familiar with the program for which the child is registering. I understand that there are risks associated with these kinds of activities. As a condition of participation in this program , I agree that I will be fully responsible for any and all personal injuries, property damage, loss of personal property, or any other loss that may result from my child’s participation, and I agree not to hold Little Ummah Academy responsible, and their respective agents and employees, to the fullest extent permitted by law, for any damages, liabilities or expenses that result from participation in this program and/or the use by the participant of the academy and /or equipment.*

I ACCEPT
I will submit the immunization records of my kids and share any medical conditions that may need further attention by the teachers.*

I ACCEPT
MEDICAL/DIETARY QUESTIONS
Physical Condition: Please list any non-allergy physical/medical conditions that would be helpful for us to know about this child.
Medications: Please list the medications and dosage your child is currently receiving, along with any special instructions.
Miscellaneous: Is there anything else that you believe it is important we know in regards to your child’s participation in this program? If so, please describe:
I understand that I may be contacted in the future by a staff member of Little Ummah Academy to inquire about my child’s experience.*

I ACCEPT
LIABILITY WAIVER
In consideration of the acceptance of my application for the above program, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to me as a result of participation in said event. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assignees.

I ACCEPT

I HAVE READ THE AGREEMENT, FULLY UNDERSTAND IT, AND GRANT PERMISSION FOR MY CHILD TO PARTICIPATE IN THE PROGRAM IDENTIFIED ABOVE.
Date*

MonthDayYear
Date
Signature of Parent or Legal Guardian:*

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Student Enrollment & Release Form

PROGRAM DETAILS