Summer Program Registration Form-June

Summer Program Registration Form-June

Please fill out the form to register your learner for the summer program of your choosing and proceed with the payment. We will send you waivers to sign upon completion of filling out this form. Tuition is due at the time of registration and is non-refundable.
Guardians Name

First NameLast Name
Student Name

First NameLast Name
Students Name (if additional siblings are registering)

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Students DOB

MonthDayYear
Date
Summer Program I am registering for
Known Allergies or Medical Conditions
Emergency Contact
Please enter a valid phone number.Format: (000) 000-0000.
I (the natural parent or legal guardian) hereby give permission that my child, * 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: *
*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: * *I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Initial:* 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:
BOTH PARENTS MUST SIGN OR PARENT/GUARDIAN WITH SOLE CUSTODY OF THE CHILD:

My Products

June 22-25

$215.00

Both weeks

$430.00 Quantity

Total

Payment Methods

Credit Card

ACH Bank Transfer

Should be Empty:

Summer Program Registration Form-June

My Products*

Payment Methods

My Products