Studios 2018-19

Enrollment Form

2018-2019

The Studios at LeyVa provides students with free access to after-school experiences. The program(s) are technology and media based. No experience necessary. Fees for this program are being covered by PEER Foundation, a 501 (c) (3) nonprofit corporation. Programs start on Thursday, September 12.

Day/Time

Location

Topic

Wednesdays,

2:20 – 4:30

Studio 1

BIZ Club

Thursdays,

2:20 – 4:30

Studio 2

Coding

Select desired workshop(s): *

BIZ Club

Coding

Student Information

Student First Name *

Student Last Name *

Grade *

School *

Parent First Name *

Parent Last Name *

Parent email *

Phone Number *

Emergency Contact Information

Name *

Phone *

Relationship *

Release of Liabilty

By completing this enrollment form, I agree to the following:

1) Parental Consent and Release

I agree to allow the enrolled student to attend and participate in any activities and events associated with this program. I hereby release, discharge, indemnify, and agree to hold harmless Evergreen School District, LeyVa Middle School and PEER (including all program staff and or volunteers) from any and all liability for personal injuries and/or damages, injury, or illness that may be incurred at these events.

and,

2) Medical Release

In the event of an emergency and in the event that I cannot be reached, I hereby give permission to program staff and or volunteers to secure emergency transportation including hospitalization, at my expense, to any hospital for the enrolled student. I release program staff and or volunteers from claim or liability due to illness or injury. I understand that this is a MEDICAL RELEASE AGREEMENT.

I confirm my agreement to the above

I agree to allow my child to be photographed or videotaped for publicity purposes for PEER Foundation promotional material. *

Yes

* Indicates Response Required

Additional comments