RPEP Enrollment Form-Academic Coaching ONLY

ENROLLMENT FORM-ACADEMIC INSTRUCTION ONLY

Registration Fees will be paid through Square and must be completed in order to complete registration process online. YOU DO NOT need to have a Square account to use this system and may use credit card or debit card. If you do not have a Square account you may sign in as a "guest". Only one child may be registered at a time.

Entrance Date*

Date

Child #1 Information

First name*

Last name*

M.I.*

Street address*

Street address line 2

City*

State*

Zip code*

Male or female?*

FemaleMale

Who does the child live with? *

Name of Public or Private School child attends, if any*

Parent's Information

Parent's/Guardian's name (MOTHER)*

Parent's/Guardian's name (FATHER)*

Home/Cellular number*

Work number*

Place of work*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Email address*

example@example.com

Emergency Contact 1
In the event of an emergency, please contact:

First name*

Last name*

Primary phone number*

Secondary phone number

Emergency Contact 2
In the event of an emergency, please contact:

First name*

Last name*

Primary phone number*

Secondary phone number

Other people authorized to pick up your child

First name*

Last name*

First name*

Last name*

First name*

Last name*

Medical information

Doctor*

Doctor's phone number*

Dentist*

Dentist's phone number*

Preferred hospital*

Is the child covered by medical insurance?*

YESNO

Name of Insurance Company (enter none if no insurance):*

Policy Number (enter none if no insurance):*

Please list any of the following: Current medications, medication allergies, food allergies, special needs/accommodations or chronic health concerns.*

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.)I, as the registered am 18 or over, or I am a parent or legal guardian of the registered who is currently under the age of 18, grant permission for the registered camper to attend Rising Phoenix Enrichment Program's Tutorial and consent to its Discipline Policy and also do hereby release Rising Phoenix Enrichment Program's Tutorial from any and all liability or responsibility due to any injury that he/she/I may incur as the result of, or arising in any way from participation in activities at or under the direction of Rising Phoenix Enrichment Program's Tutorial. I am fully aware and consent to accept these risks and voluntarily agree to allow his/her participation in activities. If I cannot be consulted in an emergency, I hereby give permission to the physician selected by a representative of Rising Phoenix Enrichment Program's Tutorial to hospitalize, secure treatment for, and to order injections, anesthesia, and/or surgery for the person named above. I understand that Rising Phoenix Enrichment Program's Tutorial only carries secondary insurance and that I will take primary responsibility for any fees or charges at any clinic, facility, or hospital arising from treatment of injury or illness. I furthermore understand Rising Phoenix Enrichment Program's Tutorial 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 Rising Phoenix Enrichment Program's Tutorial. Rising Phoenix will not identify me or my child by name, or release any other personal information without additional written permission from me.*

First NameLast Name

Current Date:*

Date

Which grade level requires Academic Coaching?

K-5 Elementary6-8 Middle9-12 High School

Which Subject requires Academic Coaching?

My Products*

1 Subject/1 Hour Elementary$35.00

1 Subject/1 Hour Middle School$45.00

1 Subject/1 Hour High School$55.00

1 Subject/2 Hours Elementary$70.00

1 Subject/2 Hours Middle School$90.00

1 Subject/2 Hours High School$110.00

ACT/SAT/PSAT Test Prep Session 1$40.00

ACT/SAT/PSAT Test Prep Session 2$40.00

Georgia Milestone Test Prep Elementary$45.00

Georgia Milestone Test Prep Middle$55.00

EOCT High School ONLY 2 Hour Session$65.00

RPEP T-Shirt$10.00

RPEP Tote Bag$20.00

RPEP Water Bottle$10.00

1 Day: Elementary In Person Online Learning$50.00

Meet on Monday's and Tuesday's ONLY

1 Day: Middle/High In Person Online Learning $50.00

Meet on Wednesday's and Thursday's ONLY

2 Day: Middle/High In Person Online Learning $100.00

Meet on Monday's and Tuesday's ONLY

2 Day: Elementary In Person Online Learning 2$100.00

Meet on Monday's and Tuesday's ONLY

Enter coupon

Total $0.00

Credit Card

For Security, type the message seen below:*

An 80% refund of is made if written notice is given to RPEP two weeks prior to your childs first day of services. A 50% refund is made if written notice is given to RPEP within 2 weeks of the start of services. No refund will be made once the services start. Canceled online store deposits and merchandise purchases will be refunded at 95% to compensate for fees RPEP has to pay.
All refunds are processed within 30 Days of written notice.

Upon completion of filling in all areas of form, click "Submit". You will then be taken to Square where you will pay and registration process will be completed. Only one camper may be registered at a time. You may click "Print Form" to print a copy of this form. Do you have questions or need help with online registration? Email us at info@risingphoenixinc.org. *Please allow 48 hours for a response.*

Withdrawal Date (DO NOT COMPLETE, AUTHORIZED USE ONLY)

Date

Type a question