Children's ASL - Winter 2024 Child's Name * Date of Birth * Parent or Caregiver * Relation * Best Contact Number * Address * Address Street Address Street Address Unit/Apt/Suite Unit/Apt/Suite City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * Emergency Contact * Relation * Emergency Contact Number * Other people that can pick up my child Special Accommodations Does your child have any medical conditions or concerns? Please indicate if there is a history of seizures, allergies or intolerances, asthma/respiratory concerns, or cardiac concerns. Children's ASL Classes * Ages 5-7 - Wednesdays - 1/8/25-2/12/25 (4:00-5:00pm) (6 weeks) -$120 Ages8-10 - Wednesdays - 1/8/25-2/12/25 (4:00-5:00pm) (6 weeks) -$120 My signature below indicates that I have read and fully understand all of the above and hereby give my permission on all points from this date forward. It is understood that once external media is published it is impossible to guarantee that the material can be relinquished 100%. Please understand that failure to sign this form will constitute approval of the above requests. * signature keyboard Clear For “drop-off” programs where a parent/guardian may not be present, I give permission for my child to be treated in an emergency. This includes emergency medical services and transport to the nearest emergency room. I understand that every attempt will be made to reach me. If I cannot be reached, each emergency contact listed will be called. If no one on the emergency contact list can be reached, I understand that attempts to reach someone will continue. I give permission for my child to be treated by the emergency room doctor/ hospital. A known staff member will accompany my child to the hospital. A staff person will stay in attendance until the parent/guardian or a school administrator relieves them. Total $ Credit Card * Month Submit If you are human, leave this field blank.
