2021-2022 Canopy Tutoring Registration

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MONDAYS, TUESDAYS, and THURSDAYS, after school - 5:00pm $25 to register

Child's first name + last name: *

Boy or Girl *

Boy

Girl

School's name + teacher's name: *

Grade for the 2021-2022 school year: *

Mailing address (please include apartment number, city and zip code): *

Parent's names / or caregiver's names: *

Cell Phone #: *

Email: *

My child qualifies for Free and Reduced Lunch *

Yes

Required

Ethnicity: *

Languages in addition to English that are spoken at home: *

Please list any food restrictions:

My child has a special need, learning disability, or medical condition? *

Yes

If yes, please describe:

Name + cell number of an emergency contact *

Health Insurance Company and Policy #: *

Emergency Treatment Release

In the event that I cannot be contacted, I give my consent for Canopy staff to administer first aid and call for emergency medical help. I consent for medical procedures to be performed for my child by a licensed physician or hospital if deemed necessary to protect my child’s health. Any expenses will be accepted by me.

Liability

I hereby hold Canopy, its agents, officers and employees harmless from, and waive, release and discharge any claim or cause of action I have, or in the future may have, for injury, accident, illness, or death occurring during or by reason of this program, including being not limited to the administration of or the non-administration of said medical treatment, first and/or medication in accordance with the consent and/or information provided above. This release is limited to discharge in advance Canopy, its agents, officers and employees from any and all liability even though that liability may arise out of negligence or carelessness on the part of the persons Canopy mentions above.

I have carefully read this authorization/release and fully understand its contents and voluntarily consent to its terms and conditions. By signing this legal document, I will waive certain legal rights, including the right to sue. Please sign below: *

My child needs shuttle transportation from Parkwood or Meridian Park:

Mondays

Tuesdays

Thursdays

Do we have permission to photograph or videotape your child for use in brochures, newsletters, or on our website? *

Yes

Comments or questions:

Please submit this form, then bring or mail the $25 registration fee to Canopy at 1315 North 160th Street, Shoreline, WA 98133.

Please contact us with any questions: lynn@canopyscholars.org | 206-819-3407

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