Art Tatum Zone High School Support Registration Form
Thank you for your interest in having your student attend our academic support and career readiness program.   The Art Tatum Zone and our partners are committed to supporting your students and family during COVID-19 by providing access to quality programming, connections to business owners and professionals, and other caring adults while following CDC and local health guidelines.
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Parent's Name *
Student's Name *
Student's 900 #
Student's birthdate *
MM
/
DD
/
YYYY
Student's gender *
Second student's name
Student’s 900#
Second student's birthdate
MM
/
DD
/
YYYY
Second student's gender
Third student's Name
Student’s 900#
Third student's birthdate
MM
/
DD
/
YYYY
Third student's gender
Fourth student's name
Student’s 900#
Fourth student's birthday
MM
/
DD
/
YYYY
Fourth student's gender
Clear selection
Grades of your student(s) (Check all that apply) *
Required
Home School *
Permission for Participation--I give permission for my student to attend the ATZ high school academic assistance and career readiness program and to participate in its programming. I hereby release and discharge the program operated under the Art Tatum Zone, its directors, officers, administrators, volunteers and other parties of every kind of injury incurred by my child while in attendance of the programs. I further agree to hold harmless and fully indemnify the Art Tatum Zone and all involved parties of interest from any and all claims, damages, costs, including attorney fees and causes of action, which may arise from any cause of action by me, or on behalf of my student. *
Required
School Release-- I hereby give permission to Toledo Public Schools to exchange information regarding the minor child listed on this application. The purpose of the exchange is to help both organizations to better prepare the student for success. *
Required
Please list any allergies and/or dietary restrictions
List any physical or cognitive limitations
Additional medical information
Caregiver Phone Number *
Secondary Phone Number *
Caregiver email address *
Caregiver Mailing Address *
Zip code *
Please identify any other needs of the student (s) and/or family. (Check all that apply)
How will your student(s) be transported to the program? *
By signing my full name below, I acknowledge I have read this complete application and this form, and am requesting that my child be admitted as a participant of one of the Art Tatum Zone's High School Academic Support and Career Readiness program sites. *
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