Charchelly's Culinary Academy
Student Enrollment Form
Parent / Guardian Information
Full Name:
First Name
Last Name
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Information
Student Name:
*
Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
*
Grade Level:
Emergency Contact
Name:
Relationship:
Phone Number:
Format: (000) 000-0000.
Medical Information
Allergies (Yes/No):
Details:
Medical Conditions:
Medication Needs:
Learning & Support Needs
Does your child need additional support?
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Dietary Restrictions
Restrictions:
Program Selection
Start Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Session:
*
Morning
Afternoon
Evening
Authorized Pick-Up Persons
Name:
First Name
Last Name
Phone:
First Name
Last Name
Relationship:
Name:
First Name
Last Name
Phone:
First Name
Last Name
Relationship:
Name:
First Name
Last Name
Phone:
First Name
Last Name
Relationship:
Liability Acknowledgment
I understand participation involves cooking risks including heat, tools, and equipment. I give permission for my child to participate.
Parent Signature
Name:
Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Class Enrollment
*
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Adaptive Learners
Children with specials needs or would need extra guidance
$880.00
$
880.00
Quantity
1
2
3
4
5
6
7
8
9
10
Non-adaptive learners
children with no disabilities
$800.00
$
800.00
Quantity
1
2
3
4
5
6
7
8
9
10
Private cooking lessons
$95.00
$
95.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
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