Child Visit Day

Child Visit Day

Application and Payment Form
Student Name*

First NameLast Name
Student Birthday*

MonthDayYear
Date
Parent/Guardian Name:*

First NameLast Name
Parent/Guardian Name:*

First NameLast Name
Authorized Pick up Persons Name*

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Program Interested in Visiting*
YesNoOther
If Yes please list all allergies and medications needed
Liability Waiver

I hereby certify that my child(ren) is/are in good physical condition and do/does not suffer from any disability that prevents or limits his/her participation in all activities conducted by Roseville Community School. I acknowledge that Roseville Community School will not assume any responsibility or liability for personal injury or damages caused by the injury. In the event Roseville Community School is unable to reach a parent, guardian or any emergency contact, I hereby give permission for my child(ren) to be transported to the nearest hospital for treatment in case of an accident or emergency. I hearby further authorize(s) any of the the staff or employees to provide for, approve and authorize health care at hospital.
Yes, I have read and agree to the terms of this Liability Waiver.No, I do not agree to the terms of this Liability Waiver.
Signature*
Photo Waiver

I hereby grant and authorize Roseville Community School the right to take, edit, copy, publish, distribute and make use of any and all pictures or video taken of my child(ren) to be used in and/or for legally promotional materials and digital communications. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing. I understand and agree that these materials shall become the property of and will not be returned.
Yes, I have read and agree to the terms of this Photo Waiver.No, I do not agree to the terms of this Photo Waiver.
Signature*

Submit payment for your students Visit Day*

Visit Day

Child Visit Day

This fee includes your child’s participation in either the Morning Program (9:00 a.m.–12:30 p.m.) or the Afternoon Program (12:30 p.m.–3:00 p.m.) time slot. Please select the session that best fits your schedule when registering.

$125.00 Quantity

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Schedule Your Students Visit Day

Please select either the morning or the afternoon you are interested in.
Please, select a visit day date and time. If interested in Morning Programs.
Please, select a visit day date and time. If interested in Afternoon Programs.
Should be Empty:

Child Visit Day

Liability Waiver

Photo Waiver

Payment Methods

Schedule Your Students Visit Day