Tiara Teas Class Registration Form

Tiara Teas Class Registration

6-Week Mentorship Program for ages 7-9, scheduled to begin April 20th, 2024. Total cost of the program is $400. The $60 registration fee is due upon submission of the application. Payment plans are available for the remaining balance of $340.00, to be discussed on the first day of class.
Parent's Information*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child #1 Information
Name*

First NameLast Name
Grade*
Child's T-Shirt Size*
Youth Size (S, M, L), Adult Size (S, M, L, XL)
Birth Date*

MonthDayYear
Child #2 Information (If Applicable)
Name

First NameLast Name
Grade
Child's T-Shirt Size
Youth Size (S, M, L), Adult Size (S, M, L, XL)
Birth Date

MonthDayYear
Please list the names of individuals that you authorize to pick up your child, outside of yourself, if applicable. Please be advised, we will check their identification before releasing the child.
Person #1 - Name

First NameLast Name
Relationship
Person #2 - Name

First NameLast Name
Relationship
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Does your child have any allergies, chronic illnesses, disabilities or medical conditions? If yes, please describe. (If multiple children are listed on this application, please be sure to let us know which child you are referring to.)*
Is your child taking any prescribed medication? Please be advised, we will not administer any medication to any child. We kindly ask that all medication be taken prior to arriving to the program.*
Is there any additional information you would like us to know about your child(ren)? Please share below.
Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Tea of Pearls during the selected classes. In exchange for my child(ren)'s acceptance into the Tea of Pearls program, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Tea of Pearls and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected classes and/or field trip sessions. In case of injury to said child, I hereby waive all claims against Tea of Pearls, including all staff and affiliates, all participants, teachers, volunteers, and, if applicable, owners and lessors of premises used to conduct the event.
Initials*
Medical Release and Authorization As Parent and/or Guardian of the named child(ren), I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the Tea of Pearls and its affiliates including Directors, Teachers, Staff and Volunteer Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence. I also understand that Tea of Pearls will not administer any medication to my child at any time.
Initials*
Photo Release Waiver I hereby authorize Tea of Pearls to use pictures of my child(ren) taken in a photograph, digital image, videotape, motion picture, and/or testimonial for marketing purposes. Marketing purposes includes social media, flyers, website, and other marketing material that Tea of Pearls will produce. I, hereby release Tea of Pearls, its agents or employees, as well as any and all users and exhibitors of said pictures, from any and all claims, demands, accountings, and causes for which the aforesaid videotape, testimonial, motion picture, digital image, or photograph likeness may be used pursuant to this Consent and General Release. It is also my understanding that I will receive no compensation for my child(ren)'s likeness or testimonial.
I agree to the terms of this photo waiver.I DO NOT agree to the terms of this photo waiver, nor do I authorize Tea of Pearls to use images, video, or any other media forms of my child for marketing purposes.
Initials*
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Please sign here:*

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Today's Date*

MonthDayYear
Date
My Products
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TIARA TEAS CLASS - REGISTRATION FEE ONLY Registration Fee $60.00 6-week Tiara Teas Class. Due at time of registration. Will be applied to the total amount of the Program Fee. Remaining balance $340.00.
$60.00



TIARA TEAS CLASS - REMAINING BALANCERemaining Program Fee $340.00 6-week Tiara Teas Class.
$340.00



TIARA TEAS (FULL PAYMENT) Includes registration and Program Fee. 6-week Tiara Teas Class.
$400.00



Total

$0.00
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