Charchelly's Culinary Academy
Student Enrollment Form
Parent / Guardian Information
Full Name:
First Name
Last Name
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Information
Student Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
*
Grade Level:
Emergency Contact
Name:
Relationship:
Phone Number:
Format: (000) 000-0000.
Medical Information
Allergies (Yes/No):
Details:
Medical Conditions:
Medication Needs:
Learning & Support Needs
Does your child need additional support?
Back
Next
Dietary Restrictions
Restrictions:
Program Selection
Preferred Start Date:
-
Month
-
Day
Year
Date
Session:
Spring
Summer
Fall
Authorized Pick-Up Persons
Name:
First Name
Last Name
Phone:
First Name
Last Name
Relationship:
Name:
First Name
Last Name
Phone:
First Name
Last Name
Relationship:
Name:
First Name
Last Name
Phone:
First Name
Last Name
Relationship:
Liability Acknowledgment
I understand participation involves cooking risks including heat, tools, and equipment. I give permission for my child to participate.
Parent Signature
Name:
Signature:
Date:
-
Month
-
Day
Year
Date
Back
Next
Class Enrollment
*
prev
next
( X )
Adaptive Learners
Children with specials needs or would need extra guidance
$880.00
$
880.00
Quantity
1
2
3
4
5
6
7
8
9
10
Non-adaptive learners
children with no disabilities
$800.00
$
800.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Continue
Continue
Should be Empty: