Annual Client Information Forms

Annual Client Information Forms

Welcome to a new year at Smart Diehl Academy! Please complete this form to register for Smart Diehl Academy’s programs for the year (valid June 2025 – May 2026). To ensure we have the most up-to-date information and appropriate authorizations, this form must be completed annually before your child begins any program or session. Thank you for helping us best support your learner!
Which program(s) will your child(ren) be participating in this year? (Select all that apply)*

Summer CampHomeschool Core Program: MWFPre-K / Kindergarten Core Program: T/ThPrivate School PathEnrichment ClassesPrivate Tutoring / Music LessonsWildRoots Nature Program

Parent/Guardian Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Child*
Would you like to add a second guardian?*

YesNo
Second Parent/Guardian
Name 2*

First NameLast Name
Email 2*
example@example.com
Phone Number 2*
Please enter a valid phone number.
Address (if different from above) 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Child 2*

Emergency Contact
Emergency Contact 1: Full Name*
Emergency Contact 1: Relationship to Child(ren)*
Emergency Contact 1: Phone Number*
Please enter a valid phone number.
Emergency Contact 2: Full Name*
Emergency Contact 2: Relationship to Child(ren)*
Emergency Contact 2: Phone Number*
Please enter a valid phone number.
Other contacts
Provide any additional emergency contact information here
List of people allowed to pick-up your child *
Notes
Any other information about pick-up drop off that we should be aware of?

Consents and Waivers
By checking each of the following boxes, I acknowledge that I am providing consent and/or waiving liability as described. These consents and waivers apply to both the Mint Hill and Midland locations of Smart Diehl Academy.
Emergency Medical Consent*

I give permission for Smart Diehl Academy staff to seek emergency care for my child if I cannot be reached or a delay would be dangerous.
Photo and Video Release

From time to time, Smart Diehl Academy takes photographs and videos of students during various activities, events, and classroom sessions. These photos and videos may be used for promotional purposes, including but not limited to: SDA website, Social media channels, (Facebook, Instagram, etc.), Promotional materials (brochures, flyers, etc.), Newsletters, and/or Educational presentations.
Please indicate your preference regarding the use of your child's photos and videos.*

Yes, Smart Diehl Academy MAY use photos or videos of your child(ren) for promotional, educational, or social media purposes.Yes, Smart Diehl Academy MAY use photos or videos of your child(ren) for promotional, educational, or social media purposes.- HOWEVER, please do not show their face.No
Bathroom/Changing Assistance Consent (Optional)*

I grant permission for Smart Diehl Academy staff to assist my child with bathroom needs and changing clothes if necessary. I understand that assistance will be provided respectfully and professionally, ensuring my child's privacy and dignity.
Outdoor Activities Information

I acknowledge that my child will participate in outdoor play activities with Smart Diehl Academy. I understand that outdoor play involves inherent risks, including but not limited to slips, falls, collisions, and exposure to outdoor elements. I hereby waive and release Smart Diehl Academy, its staff, teachers, and affiliates from any and all liability for injuries, accidents, or incidents that may occur during outdoor activities, to the fullest extent permitted by law. I understand that Smart Diehl Academy takes precautions to minimize risks, but I acknowledge that accidents can happen despite these measures. I agree to indemnify and hold harmless Smart Diehl Academy, its staff, teachers, and affiliates from any claims, damages, or expenses arising out of my child's participation in outdoor activities.
Outdoor Activities Waiver*

I understand that my child will participate in outdoor learning and play activities. I accept the inherent risks and agree to hold Smart Diehl Academy harmless.
Activities Liability Information

I acknowledge that my child may participate in activities including but not limited to physical education, gardening, yoga, arts and crafts, science experiments, or other pursuits (hereinafter referred to as "activities"), at Smart Diehl Academy. I understand that participation in these activities involves inherent risks, including but not limited to physical exertion, use of equipment or tools, exposure to natural elements, and potential contact with allergens or hazardous materials. In consideration of my child being permitted to participate in these activities, I hereby waive, release, and discharge Smart Diehl Academy, its officers, directors, employees, agents, volunteers, and affiliates from any and all liability for injuries, accidents, or incidents that may occur as a result of my child's participation in these activities, to the fullest extent permitted by law. I understand and acknowledge that Smart Diehl Academy takes precautions to minimize risks associated with these activities, but I recognize that accidents can happen despite these measures. I accept full responsibility for any injuries or damages that may occur to my child during their participation in these activities. I agree to indemnify and hold harmless Smart Diehl Academy, its officers, directors, employees, agents, volunteers, and affiliates from any claims, damages, or expenses arising out of my child's participation in these activities.
Activities Liability Waiver*

I understand that Smart Diehl Academy programs may include physical movement, science experiments, gardening, and creative activities. I accept the risks involved and waive liability for typical participation.

Signature & Submission
Final Consent Statement

I certify that I have read and understand the information on previous pages, and I voluntarily agree to their terms. By signing below, I acknowledge and agree to their application to all services provided by Smart Diehl Academy at both the Mint Hill and Midland locations.
Signature*

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Annual Client Information Forms

Parent/Guardian Information

Second Parent/Guardian

Student Information: Child 1

Medical & Emergency Info

Medication

Emergency Response

Bathroom Routines (if applicable)

Student Information: Child 2

Medical & Emergency Info

Medication

Emergency Response

Bathroom Routines (if applicable)

Student Information: Child 3

Medical & Emergency Info

Medication

Emergency Response

Bathroom Routines (if applicable)

Student Information: Child 4

Medical & Emergency Info

Medication

Emergency Response

Bathroom Routines (if applicable)

Emergency Contact

Client Agreement

Fees

Payment Policies

Cancellation Policy

Late Arrival and Schedule Changes

Late Pickup Policy

Non-Interference With Advantageous Contractual Relationships

Obligation of Services

Termination of Services

Smart Diehl Academy Policies and Guidelines

Sickness Policy

Safety Guidelines

Outdoor Policy

Procedures and Respect for Our Space

Applicable Locations

Consents and Waivers

Photo and Video Release

Outdoor Activities Information

Activities Liability Information

Signature & Submission

Final Consent Statement