2019-2020 Clubhouse Registration
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Email *
In you have multiple children to register, please fill out separate forms for each child.
Student's First Name *
Student's Last Name *
Please note your child/ren's Clubhouse schedule
**If your schedule changes, please check other and submit your schedules on MyProcare by Thursday for the following week.  If you do not have a Clubhouse schedule submitted and you do not communicate with the homeroom teacher and Clubhouse coordinator your child's end of day will be whatever the teacher has noted as "regular".
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Required
If other, please give a general idea of your needs for staffing purposes.  Example - 3 days per week or drop in.
Parental Consent: I have read, understand, and agree to the Cologne Academy Clubhouse policies as stated in the Cologne Academy Clubhouse handbook. I give permission to Clubhouse to take my child/ren on supervised neighborhood field trips. I give permission to Clubhouse staff, in an emergency situation, to administer whatever emergency (first aid, disaster evacuation) measures are judged necessary for the care and protection of my child/ren while under the supervision of Clubhouse.  I give permission to Clubhouse to take whatever emergency measures are judged necessary for the care and protection of my child while under the supervision of Clubhouse. In case of a medical/life-threatening emergency, I understand that my child will be transported, at my expense, to the nearest hospital by local emergency personnel as they deem necessary. It is understood that in some medical situations, the staff will need to contact the local emergency personnel before the parent and/or other adult acting on the parent’s behalf.  Cologne Academy reserves the right to make decisions about enrollment and participation in our activities and programs.  I hereby release Cologne Academy and all adult leaders from any liability and from any and all claims against them, individually or collectively, for any injuries which might be received during this field trip or activity, or in traveling to and from such field trip destinations.
All billing, attendance, family and emergency contact information is done through Procare.  If you don't already have an account, you will need to create one here:  https://www.myprocare.com/Default/Index?aWtuPTQ1ODQ5MDAwOTQmc2NoSWQ9Mg==
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By electronically signing this form you are agreeing to the permission terms and giving your permission for your child to attend Clubhouse.
Parent/Guardian Signature *
If you have any questions please contact Cathy Kerber at ckerber@cologneacademy.org
A copy of your responses will be emailed to the address you provided.
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