LANGTREE CHARTER After School Registration

Student's Full Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Birth Date *

Month Day Year

Gender: *

Male Female

Phone Number *

- Area Code Phone Number

E-mail Address where you'd like to receive confirmation and information: *

Grade *

Who will be picking the student? List name and best phone numbers

List any medical food allergies: (If none, enter none) *

List any chronic illness and or physical limitations that staff should know about: (If none, enter none) *

List all current medications: (If none, enter none) *

Electronic Signature: By entering my name below, I accept the above conditions and releases. (You must be 18 years old or over to sign below.) *

First Name Last Name

Relationship to registered Student: *

Current Date: *

- Month - Day Year

CHOSE YOUR SESSION *

Mar 4 - Apr 8 $ 145.00

Quantity
Item subtotal: $ 0.00

I would like to make a donation to help another student to attend the STEM After-School Program (100% Tax Deductible) $ 1.00

Check Amount of Donation

Total $ 0.00

CONSENT STATEMENT

As the parent/guardian of the above-named student, I certify that my child/ward has my permission to attend and participate in the Kids-N-Technology (KNT) computer program and that he/she elects to engage in all program activities, at his/her own risk and hereby consent to hold harmless and release KNT and its owners, successors, agents, and employees from any and all liability that may accrue from personal injuries to said applicant. I also understand that if my child does not conform to the behavior expectations and rules of the program, KIT reserve the right to dismiss my child/ward and that there shall be no refunds for such dismissal. I further understand that I will be responsible for any personal or property damage incurred by my child/ward while participating program and that KIT is not responsible for personal belongings lost, damaged, or stolen.Furthermore, I understand that KNT often takes photographs or videos of participants during its activities or events. I grant permission without compensation that these photographs or videos may be used in publications, presentations, websites or promotion of KNT. Finally, KNT will not identify me or my child by name, or release any other personal information without additional written permission from me.

REFUND POLICY

80% of refund is given before the session starts. No refund will be made once the session starts. We do not prorate fees for non attendance.

Upon completion of filling in all areas of form, click "Submit Form". You will then be taken to PayPal where you will pay and registration process will be completed. Only one student may be registered at a time. You may click "Print Form" to print a copy of this form. If you have questions or need help with online registration? Email us at info@kidsntechnology.net

For Security, type the message seen below: *

LANGTREE CHARTER-COED STEM Club