Kids Academy Registration 2022-23

Student Information

Student Name(Required)

First Last

Birth Date(Required)

Gender(Required)

Male

Female

Grade in Sept 2022(Required)

Does the student have a sibling registered or will register to Kids Academy or Youth Mentorship program this term?(Required)

Yes

No

Primary Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent / Guardian Information

Father Name(Required)

First Last

Father Phone(Required)

Father Email(Required)

Mother Name(Required)

First Last

Mother Phone(Required)

Mother Email(Required)

Emergency Contact Information

Please list a contact that is not listed on this form, to be used if Parent / Guardian cannot be reached

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Emergency Contact Email(Required)

Relationship to Student(Required)

Physician Info

Do you have a physician(Required)

Physician Name(Required)

First Last

Physician Phone(Required)

Any specific condition that we need to know about your kid?

Does your child have a Medical Condition.(Required)

Medical Info

I hereby state that my son/daughter whose name appears on the first page of this document under ‘Student Information’ has the following medical condition(s) that the BE&C staff should be aware of during the school. I hereby state that I have provided the necessary medication to the BE&C staff. I instructed them how to give the medication to my child if need arises, and give permission to administer the medication to my child. I hereby state that my son/daughter is otherwise in good physical health condition to participate in the activities provided by BE&C, including but not limited to all aspects of running, and folk dance training, basketball, soccer and or competition. I am fully aware that any activity involving motion, height or athletic activity creates the possibility of injury. I hereby state that I have provided the necessary medication to the BE&C staff. I instructed them how to give the medication to my child if need arises, and give permission to administer the medication to my child. I hereby state that my son/daughter is otherwise in good physical health condition to participate in the activities provided by BE&C, including but not limited to all aspects of running, and folk dance training, basketball, soccer and or competition. I am fully aware that any activity involving motion, height or athletic activity creates the possibility of injury.

Medical Condition 1

Required Medication for Condition 1

Medical Condition 2

Required Medication for Condition 2

Additional Medical Conditions and their Medication

Consent

Media Liability Release

I agree to the privacy policy.

I consent to and acknowledge that my child/ student listed in registration may be photographed/recorded at all times during the programs by the Boston Education and Counseling staff for promotional and interorganizational purposes.

Consent(Required)

I have read and I agree to the policy.

I hereby release and agree to hold Boston Education and Counseling harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the BEC, or that may otherwise arise in any way in connection with any services received from Boston Education and Counseling. I understand that this release discharges Boston Education and Counseling from any liability or claim that I, my heirs, or any personal representatives may have against the BEC with respect to any bodily injury, illness, death, drawn, medical treatment, or property damage that may arise from, or in connection to, any services received from Boston Education and Counseling. This liability waiver and release extends to the BEC together with all owners, partners, and employees. Assumption of Risk and Waiver of Liability: In consideration of the above, I assume all risks associated with the preparation of food products supplied under this Agreement, including matters of health and safety associated thereof. I do hereby release, waiver, discharge, and covenant not to sue Boston Education and Counseling, and their respective Trustees, officers, employees, students and agents from liability from any and all claims including the negligence of said organizations and their respective Trustees, officers, employees and agents, resulting in personal injury, accident, or illness, including death and property loss arising from any and all food products provided under this Agreement. By registering to the Kids Academy Program hosted by Boston Education and Counseling.

Payment

The Cost for this year is $900 per student. We have a %12.5 discount for each sibling registered for our programs. For any additional information please contact kids@bostoneducation.us

Payment Strategy(Required)

Kids Academy Registration(Required)

Price:

Kids Academy Registration(Required)

Price:

Kids Academy Registration - 2 Payments(Required)

Price:

The second payment is due Jan 15, 2023. You will be receiving an email.

Kids Academy Registration - 4 Payments(Required)

Price:

The second payment is due Nov 15, 2023. You will be receiving an email.

Kids Academy Registration - 2 Payments(Required)

Price:

The second payment is due Jan 15, 2023. You will be receiving an email.

Kids Academy Registration - 4 Payments(Required)

Price:

The second payment is due Nov 15, 2023. You will be receiving an email.

Credit Card

Card Details

Cardholder Name

Coupon

Total