Clone of Stillwater Field School Registration Form

Stillwater Field School, Homeschool Enrichment, Registration Form

Homeschool Enrichment Program
Parent(s) or Guardian(s) Name(s)*
Email Address*
Student's Name*
Student's Gender*

MaleFemale
Student's Birthday*
Contact Number*
Do you recieve Text at this number?*

YesNo
Address*
City*
Zip Code*
Please Select your Preferred Session*

Tuesdays 12:30-3:30pm ($165 per month)Thursdays 12:30-3:30pm ($165 per month)Tuesday & Thursday 12:30-3:30 ($300 per month)
Please Select your Preferred Location*

SFS at Sweet Mercy Farm (South Spokane)
There is an annual $150 registration/supply fee,

per family, due once your learner has been admitted.

This can be paid through Square.

Last Month's Tuition is also due at the time of registration. (Non-refundable)

There is a 10% discount on tuition for families enrolling more than one child.
We occasionally take pictures of the kids in action, we hope to use these to keep parents up to date on the happenings at school through our parent-connection app. We also occasionally post photos to our social media or website.
Please click yes if you WILL give permission to have photographs of your child taken*

YesNoOnly for the parent-connection App (no socials)Only for Website & AppOnly for Flyers/Advertisements & App
Parent/Guardian Name of Employer*
Parents are:*

MarriedLiving TogetherDivorcedSeparatedWidowedSingle
Please list the people who have *Permission* to pick up your child. *Note: Anyone picking up your child must have a picture ID. Include Name, Number, Relationship to child*
Please list those persons who *Do Not Have Permission* to pick up your child.Please explain the reason or talk with us so we are aware of the situation.If the person is a legal parent or guardian, we must have a copy of a court ordered restraining order.
List TWO LOCAL Emergency Contacts (other than parents or guardian). Include Name, Number, Relationship to child. *
Regular Medication taken by Child
Child's Blood Type*
Medicine Child is Allergic to
Food Allergies
Any other Allergies
Any special health conditions?

YesNo
Has your child ever been evaluated for: ADD/ADHD, Autism, Behavior Differences, Depression*

YesNo
Does your child currently have an IEP?*

YesNo
My child has Hearing, Visual, or Speech differences*

YesNo
Stillwater Field School does not discriminate because of race, religion, gender, culture, or ability. The information you provide helps us learn more about your child and family preference and beliefs, to help your child learn and grow.
Religious provisions we should be aware of (ex: foods to not eat, Holidays to not celebrate, ect)
Cultural practices we should be aware of
Does your child have any previous peer group interactions (daycare, church groups, play groups,ect) YES/NO. If yes what type of interactions and what is their comfort level:*
List any specific strengths, interests or dislikes/fears (ex. art, leadership, favorite toys, activities, security objects) yourchild has that might help us get to know them better:*
What are your goals for your child while attending Stillwater Field School:*
Any other information you would like to provide us with to help us learn alongside your child:
I hereby sign that all information I have provided is true and up to date as of, Today’s Date: blanks* Parent/Guardian name:blank Signature: Signature
I (the natural parent or legal guardian) hereby give permission that my child, blanks* may be given emergency medical treatment to include First Aid and CPR by a qualified child care provider at Stillwater Field School. I further authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by a licensed
physician, dentist, health care provider, or hospital when deemed necessary or advisable by the physician to safeguard my child’s health. I waive my right of informed consent to such treatment. *I give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment. Initial: blank*
*I give my permission for my child to be transported off-site should the center need to be evacuated in the event of an emergency. Initial: blanks* *I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Initial:blank* If you choose not to give permission, please provide a court signed waiver and alternate emergency plan in case you cannot be reached.
BOTH PARENTS MUST SIGN OR PARENT/GUARDIAN WITH SOLE CUSTODY OF THE CHILD:*

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BOTH PARENTS MUST SIGN OR PARENT/GUARDIAN WITH SOLE CUSTODY OF THE CHILD:*

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Date*

MonthDayYear
Date
This authorization shall remain valid until revoked by me, (the parent or guardian) in writing. Authorizations to this form can only be done by parent(s) who have completed & signed the form Initial:blanks*
I commit to registering my child for the 2026/2027 school year and recognize that my $150 security deposit is non-refundable.*

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How did you find us?*

FlyerGoogle/Other search engineSocial MediaFriendOther
If you were referred by a friend please let us know who, so we can thank them!
What is your preferred method of payment? Credit card (3.5% charge) OR ACH (1% charge).*

Credit CardACH
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Stillwater Field School, Homeschool Enrichment, Registration Form

Stillwater Field School does not discriminate because of race, religion, gender, culture, or ability. The information you provide helps us learn more about your child and family preference and beliefs, to help your child learn and grow.