Cowboy Academy Program Registration

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Cowboy Academy Programs are free of charge and available to all students enrolled in Conrad Public Schools' Kindergarten through 6th grade. K-3 grade programs are held at Meadowlark and 4-6 grade programs are held at Utterback. Programming begins September 12 and registration is required before beginning.
Please contact Keri VanDyke with any questions keri.vandyke@conradschools.org

Email *

Student first name *

Student last name *

Age *

Birth Date *

YYYY

Current Grade *

Child's Teacher *

Parent/Guardians - Father & Mother Full Name *

Mother Telephone - Main # for Contact *

Father Telephone - Main # for Contact *

Address *

Local Emergency Contact OTHER than Parent *

Emergency Contact Phone number *

Emergency contact relationship to student *

Person #1 authorized to pick up student and the relationship to student. *

Person #1 telephone contact *

Person #2 authorized to pick up student and relationship to student. *

Person #2 telephone contact *

Person #3 authorized to pick up student and relationship to student. *

Person #3 telephone contact *

Parental Release and Photo consent

Type your name as you would sign

I, the undersigned (as a parent or guardian or the participant, a minor) hereby give permission for mutual exchange of information between Cowboy Academy Summer Programs and the Conrad Public Schools regarding health and safety issues, immunization records and academic achievement. *

For internal use, I acknowledge that the Cowboy Academy Summer Program may utilize film, print, and digital images of a student, which may be taken during involvement in the program activities. I consent to such uses and hereby waive all rights to compensation. *

Medical Information and Release

Type your name as you would sign.

Doctor Name *

Phone number *

Serious Health Problems - please list *

Medications - please list (STAFF WILL NOT MEDICATE CHILDREN. PARENTS/GUARDIANS ARE ENTIRELY RESPONSIBLE FOR MEDICATIONS AND FOR PERSONALLY ARRANGING FOR OR INSURING THE PROPER AND TIMELY MEDICATING OF THEIR CHILD) *

I, the undersigned (as parent, or guardian of the participant, a minor) hereby authorize the staff of the Cowboy Academy Summer Program to consent to medical, surgical, or dental examination and/or treatment. In case of emergency, I hereby authorize treatment and/or care at any hospital or by licensed medical personnel. *

Date *

YYYY

Comments/Other

Please leave any comments or other information that you feel is important for staff to know.

Comments/Other

A copy of your responses will be emailed to the address you provided.

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