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 Online Registration Draft 2-Online Registration-Sumac  
 Sumac Elementary School Online Class Registration
Online Registration
Registration
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How did you hear about us? *          * - denotes required fields
Family Information:
Family Name:
Billing Contact First Name:* Last Name: * Type:*
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
 
Contact #2 First Name:* Last Name: Type:*
Home Phone: Cell #: Work #:
Email: (Emails are kept confidential)
 
Address: *
City: * State: * Zip: *
Home Phone: *
Emergency Contact Info.:
(Not Billing Contact, Contact #2)
Health Insurance Carrier:
Volunteer preference:
Referred By:
YMCA Discount:
Ethnicity:
:
 

Student #1 Information:
Student's First Name: * Last Name: *
Student Gender:  Birth Date: * (format=mm/dd/yy) 
Transportation:
Special Needs:
Immunization Notes:
Skill Notes:
Teacher's Name?:
Authorized Pickup Contact?:
ID expiration:
contract expiration:
Who referred you to us?:*

Classes
Select Class #1: _______________ Search Classes
Select Class #2: _______________ Search Classes
Select Class #3: _______________ Search Classes
Select Class #4: _______________ Search Classes
Select Class #5: _______________ Search Classes

Student #2 Information:
Show-Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: (format=mm/dd/yy) 
Transportation:
Special Needs:
Immunization Notes:
Skill Notes:
Teacher's Name?:
Authorized Pickup Contact?:
ID expiration:
contract expiration:
Who referred you to us?:*

Classes
Select Class #1: * _______________ Search Classes
Select Class #2: _______________ Search Classes
Select Class #3: _______________ Search Classes
Select Class #4: _______________ Search Classes
Select Class #5: _______________ Search Classes

Student #3 Information:
Show/Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: (format=mm/dd/yy) 
Transportation:
Special Needs:
Immunization Notes:
Skill Notes:
Teacher's Name?:
Authorized Pickup Contact?:
ID expiration:
contract expiration:
Who referred you to us?:*

Classes
Select Class #1: * _______________ Search Classes
Select Class #2: _______________ Search Classes
Select Class #3: _______________ Search Classes
Select Class #4: _______________ Search Classes
Select Class #5: _______________ Search Classes

Student #4 Information:
Show/Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: (format=mm/dd/yy) 
Transportation:
Special Needs:
Immunization Notes:
Skill Notes:
Teacher's Name?:
Authorized Pickup Contact?:
ID expiration:
contract expiration:
Who referred you to us?:*

Classes
Select Class #1: * _______________ Search Classes
Select Class #2: _______________ Search Classes
Select Class #3: _______________ Search Classes
Select Class #4: _______________ Search Classes
Select Class #5: _______________ Search Classes

Student #5 Information:
Show/Hide Details
Student's First Name: Last Name:
Student Gender:  Birth Date: (format=mm/dd/yy) 
Transportation:
Special Needs:
Immunization Notes:
Skill Notes:
Teacher's Name?:
Authorized Pickup Contact?:
ID expiration:
contract expiration:
Who referred you to us?:*

Classes
Select Class #1: * _______________ Search Classes
Select Class #2: _______________ Search Classes
Select Class #3: _______________ Search Classes
Select Class #4: _______________ Search Classes
Select Class #5: _______________ Search Classes
 
Transportation Release
This allows me to type in anything that I want.....
...
I've read the above and agree.
 
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Please select the number of class cards (5 class card - $100, 10 class card - $160.00, 20 class card - $280, 30 class card - $360 or unlimited classes - $400) you are purchasing and post that number in the comment section at the bottom of this registration form just above the credit card verification section.


If you are enrolling in the unlimited class card, you need to only register for that class and not each individual class you plan to attend. You will be charged for the number of class cards you select and a $15.00 registration fee if you are a new student. We will have a class card ready for you when you come to your first class.

Please make sure you provide your credit card information for online registration payment.
I've read the above and agree.
 
Assumption of Risk
Assumption of risk text....

I've read the above and agree.
 
Release of Liability
As the legal parent or guardian, I release and hold harmless ____________________, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, include

I've read the above and agree.
 
Late Payment Information
Tuition is based on a 4 week session and is due before the session starts. We can't hold your space in class until payment is received


There is a $30.00 returned check charge for any checks returned by the bank.
I've read the above and agree.
 
Signature Text
As the legal parent or guardian, I release and hold harmless ____________________, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of _________________, its owners and operators or in route to or from any of said premises.
I've read the above and agree.
 
Medical Emergency
The undersigned gives permission to ____________________, its owners and operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restictions, or condition and/or declare the paricipant to be in good physical and mental health.


I request that our doctor/physician ________________ be called and that my child be transported to ______________________ hospital. Please include physicians' phone number _______________.
I've read the above and agree.
 
test tuition flow
FALL 2009

PLEASE NOTE THAT DISCOUNTS FOR MULTIPLE STUDENTS WITHIN A FAMILY WILL BE GIVEN UPON TUITION POSTING TO YOUR ACCOUNT. Upon registration, each student must pay a registration fee and May 2010 tuition. If you choose not to participate in EFT, you must also pay a $45 administrative fee, due with registration. All tuition and fees paid are non-refundable.



1 HR or less.......... $60 per month
1.5 HR.....................$80
2 ........................$90
2.5 HR.....................$100

3 HR........................$115
3.5 HR.....................$125

4 HR........................$130
4.5 HR.....................$145

5 HR........................$150
5.5 HR.................... $155

Unlimited................$165

I've read the above and agree.
 
like on jeffs
  1. I understand the Director reserves the right to dismiss any camper whose behavior/attitude is disruptive or detrimental to the welfare of the camp. No refund will be given in the event of dismissal. It is the parent's responsibility to arrange transportation for early dismissal.
  2. I authorize the use of my child's photograph in any camp publications (i.e. website, brochure, etc.).
  3. I am aware that the $50 non-refundable deposit guarantees only the week for which my child was accepted; it does not guarantee a spot if he/she elects to change into a different week at a later date.
  4. If my child is not at camp by 5:30 PM on Sunday of his/her selected week, then, at the Camp Director's discretion, my child may be deemed to have forfeited his/her space, and the space will be offered to another camper due to the waiting list that we have in many weeks.
  5. Any bounced checks will incur a $20 processing fee.

I've read the above and agree.
 
#10
tenth record - 10 records is the Max at this time. Aug 2009
I've read the above and agree.
 
 

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