January - June 2027 Moving Field Guide After School Program Registration Form

Moving Field Guide After School Program

Registration Form

Program Year: January 4 – June 11, 2027

Student Ages: 7–11
Grades: 2-5

(For parents with 1st graders / 6 year olds, please reach out to Dance Exchange directly to inquire about availability for your child - stephenc@danceexchange.org)

Complete this form to enroll your child in the 2026-2027 MFG After School Program. For more information, please visit: danceexchange.org/mfg-aftercare
Section 1: Parent/Guardian Information
Parent/Guardian 1 First Name
Parent/Guardian 1 Last Name
Parent/Guardian 1 Relationship to Student
Parent/Guardian 1 Email Address
example@example.com
Parent/Guardian 1 Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 1 Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 1 Preferred Method of Communication
Parent/Guardian 2 First Name
Parent/Guardian 2 Last Name
Parent/Guardian 2 Relationship to Student
Parent/Guardian 2 Email Address
example@example.com
Parent/Guardian 2 Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 2 Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Section 2: Home Address
Street Address
Apartment / Suite
City
State
ZIP Code
Section 3: Student Information
Student First Name
Student Last Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Grade for 2026–27 School Year
School Attending
Teacher
Does your child have any allergies, including food allergies?
If yes, please describe the allergies
Does your child have any medical conditions that we should know about?
Will your child need medication during program hours?
If yes, please explain the medication needs
What activities does your child enjoy most?
What helps your child feel comfortable in a new environment?
What do you hope your child gains from this program?
Is there anything else that you would like us to know about your child?
Section 4: Enrollment Selection

Enrollment Option	Tuition (Jan-June)	Monthly Cost	Required Deposit
2-day (M/W or T/Th)	$ 2,040	$ 340	$ 200
Full Week (M,T,W,Th,F)	$ 3,900	$ 650	$ 200
Monday Only (1-day)	$ 1,020	$ 170	$ 200

* Requiried deposit is applied to your total tuition

Section 5: Tuition Payment Preference
Please indicate your preferred payment option
Dance Exchange will send an invoice in alignment with the option you select above.
Section 6: Accessibility & Learning Supports
What accommodations at Dance Exchange would help support your child?
Is there anything else you would like Dance Exchange personnel to know?
Section 7: Authorized Pick-Up
Authorized Adult #1 Full Name

First NameMiddle NameLast Name
Authorized Adult #1 Relationship to Child
Authorized Adult #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Adult #2 Full Name

First NameMiddle NameLast Name
Authorized Adult #2 Relationship to Child
Authorized Adult #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Adult #3 Full Name

First NameMiddle NameLast Name
Authorized Adult #3 Relationship to Child
Authorized Adult #3 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Section 8: Emergency Contact
Emergency Contact #1 Full Name

First NameMiddle NameLast Name
Emergency Contact #1 Relationship
Emergency Contact #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Section 9: Permissions
Walking permission - I give permission for Dance Exchange staff to walk my child from school to Dance Exchange each scheduled program day.
First aid authorization - I authorize Dance Exchange staff to administer basic first aid for my child, if needed.
LIABILITY RELEASE: I acknowledge that I have voluntarily enrolled my child in this program and assume responsibility for all risks of injuries resulting from our participation in activities with Dance Exchange. I certify that my child is physically and mentally capable of participating in these activities. I hereby represent that I have informed Dance Exchange of any pertinent medical conditions that may affect participation in these activities, including but not limited to classes, rehearsals, performances, or related events. I voluntarily agree to release, discharge, and hold harmless Dance Exchange for any and all claims of liability which causes injury, whether based on allegations or not, in any way. Should emergency medical services become necessary for the undersigned participant, the expenses are the sole responsibility of myself and not that of Dance Exchange. I understand that this agreement is between myself and Dance Exchange, its owners, officers, board, agents, and employees and that it cannot be modified or changed in any way by the representatives or statements by Dance Exchange or by myself.
PHOTO / VIDEO MEDIA RELEASE: I hereby grant to Dance Exchange the irrevocable and unrestricted right to use and publish, alter, and copyright quoted material, photographs or video images of me or my child, including audio recordings, text / writings / drawings produced for Dance Exchange publications, electronic reproductions (website) and/or any other purpose and in any manner or medium an unlimited number of times in perpetuity for any lawful purpose. I hereby release the photographer / videographer / documenter and the Dance Exchange from all claims and liability relating to said media. I understand that the Dance Exchange will exercise extreme care in protecting the context of quoted material or image. I understand that I will not receive any monetary compensation for the permissions I am granting herein. I understand that I cannot withdraw this consent after I submit this form and that this consent and release is binding.
Supervised Outdoor Exploration Walks

Moving Field Guide Aftercare includes regular walks and outdoor exploration in the Takoma Park community. Throughout the program year, children may walk with Dance Exchange teaching artists and staff to nearby parks, gardens, and other locations identified on the Moving Field Guide Exploration Map.
Do you give permission for your child to participate in these supervised walks and outdoor explorations as part of Moving Field Guide Aftercare?
Sunscreen Permissions
Sunscreen Application - Do you give permission for your child to apply their own sunscreen, provided by your family and labeled with your child’s name, during Moving Field Guide Aftercare as needed?
Insect Repellant Permissions
Insect Repellent Application - Do you give permission for your child to apply their own insect repellent, provided by your family and labeled with your child’s name, during Moving Field Guide Aftercare as needed?
Section 10: Transportation Confirmation
Please confirm your child's school dismissal location:
If you selected "Other," please enter your child's school dismissal location below:
Section 11: Parent Agreement
Agreement to Pick Up by 6:00 PM
Tuition Policies and Payment Obligations
$200 Deposit Requirement
Please select your enrollment option.
Program Description and Expectations
Parent/Guardian Full Name
Electronic Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearPlease enter today's date
Should be Empty:

Section 1: Parent/Guardian Information

Section 2: Home Address

Section 3: Student Information

Section 4: Enrollment Selection

Section 5: Tuition Payment Preference

Section 6: Accessibility & Learning Supports

Section 7: Authorized Pick-Up

Section 8: Emergency Contact

Section 9: Permissions

Section 10: Transportation Confirmation

Section 11: Parent Agreement