Admission Application CEC & ORS

Admission Application 2022-2023

Child Enrichment Center & The One Room Schoolhouse
Student's Name

First Name Last Name
Age
Birth Date:

Month Day Year
Date
Parent's Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Education thus far:

Public Preschool Homeschool None Other
Please describe your child's academic and character strengths and challenges:
How do you describe your child's classroom behavior or demeanor? (if not been in a classroom before put N/A)
Do you think your child will have trouble with drop offs at school?
Are you able to help out in the classroom if needed?
Please select the school schedule of your choice:
Does this child/student have a diagnosis of ADD/ADHD Autism or other developmental delay? If so please describe how we can help.
Accident Waiver and Release of Liability

Child Enrichment Center & One Room Schoolhouse
If Participant is under 18 years of age, the Participant's parent or legal guardian must enter into this Agreement on Participant's behalf by signing below.
In consideration of ________________ (hereinafter, "Minor(s)")

Child's First Name Child' Last Name
being permitted by Released Parties to participate in the activities described herein, I agree to release from liability, indemnify and hold harmless Released Parties from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation by Minor. I representthat I have a legal right to enter into this Agreement on behalf of the Minor.
I HEREBY ASSUME ALL OF THE RISKS OF MY CHILD PARTICIPATING IN ANY/ ALL ACTIVITIES associated with educational, social, and therapuetifc activities at the home of Sarah Haws-Taylor & Jackson Taylor at the following location 2905 MT Adams View Dr, West Richland, WA 99353, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault.

In consideration of permitting me to participate in the educational and social opportunities afforded me, I hereby take action for myself ( or, as applicable, my minor child), my executors, administrators, heirs, next of kin, successors, and assigns as follows:

(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to,liability arising from the negligence or fault of the entities or persons released, for my death,disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from the activities herein described, THE FOLLOWING ENTITIES OR PERSONS: Sarah Haws-Taylor & Jackson Taylor and their immediate family, their employees, volunteers, representatives, and agents (the "Released Parties").

(B) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or personsmentioned in paragraph (A) from any and all liabilities or claims made as a result of participation inthe activities herein described, whether caused by their negligence or otherwise.

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during the activities herein described.

The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.

I have read and understood this document and I agree to be bound by its terms.
Signature

Clear
Parent/Guardian's Name

First Name Last Name
Date Signed

Month Day Year
Date
Emergency Contact Information
Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Relationship
Additional Pickup People
Photo Release

Video surveillance & video/photos sharing on fileshare for documentation
I, (Parent Name) legal guardian of

First Name Last Name
(child) grant Child Enrichment Center and The One Room Schoolhouse my

First Name Last Name
permission use the photographs (without names and mayremove personal identiy upon request) from school activities for any legal use, including but not limited to: publicity, copyright purposes, illustration, advertising, social media and web content for the school year 2022.

Furthermore, I understand that no royalty, fee or other compensation shall become payable to me by reason of such use.
Signature

Clear
Should be Empty:

Admission Application 2022-2023

Accident Waiver and Release of Liability

Emergency Contact Information

Photo Release