youthregistration

Student Information

Student Name(Required)

First Last

Birth Date(Required)

Gender(Required)

Male

Female

Grade in September 2024(Required)

Student Phone(Required)

Student Email(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

Have registered your student to our programs last year?(Required)

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 Parents 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)

Additional Info

Additional info can consist of any information that you would like us to know about the child, medical or other.

Is there anything you would like to notify us about the child(Required)

Please list any medical or other conditions you would like to notify us about the child(Required)

Consent

Consent(Required)

I have read and I agree to the policy.

I understand that in the event of an emergency affecting my child while participating in Boston Education and Counseling (BE&C) programs, a designated employee of BE&C will contact me and inform me as soon as possible. In the event I cannot be reached, I hereby give permission for my child to be treated or hospitalized by a licensed physician or hospital selected by BE&C.

Media Liability Release

I have read and I agree to the 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 Youth Mentorship Program hosted by Boston Education and Counseling.

Payment

The cost for this year's Youth Mentorship Program ranges from $1,500 to $1,900, with a minimum price of $1,500. We offer a 12.5% sibling discount for each additional sibling registered in the program. For families opting for financing, there are two payment options available: a two-payment plan, which adds $50 to the total cost, and a four-payment plan, which adds $100 to the total cost. Please note that the payment plans are based on the minimum payment of $1,500. For example, if the base price is $1,500, the two-payment option would bring the total to $1,550, while the four-payment option would bring it to $1,600. We highly encourage families to consider paying the full price of $1,900 if possible, as this would relieve us of financial stress and allow us to continue providing high-quality programs and services to the students. For further details, please contact us at finance@bostoneducation.us.

Payment method(Required)

Youth Program - Minimum Payment(Required)

Price:

Minimum Payment

Youth Program - Median Payment(Required)

Price:

Median Payment

Youth Program - Median Payment(Required)

Price:

12.5% Sibling Discount

Youth Program - Full Payment(Required)

Price:

Youth Program - Full Payment(Required)

Price:

12.5% Sibling Discount

Youth Program - Minimum Payment(Required)

Price:

12.5% Sibling Discount

Youth Program - Two Payments(Required)

Price:

Youth Program - Two Payments(Required)

Price:

12.5% Sibling Discount

Youth Program - Four Payments(Required)

Price:

Youth Program - Four Payments(Required)

Price:

12.5% Sibling Discount

Coupon

Total

Payment Method*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Youth Program Registration 2024-2025

Student Information

Parent / Guardian Information

Emergency Contact Information

Physician Info

Additional Info

Consent

Payment

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