Enriched Minds Registration Form
Parents,
Please complete the form below to register your child for our Summer Classes!
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Student's First and Last Name *
Gender *
Birth Date (mm/dd/year) *
Age and Grade Level *
Teacher (If at Encino Elementary)
Which Class or Classes are you signing up for? *
Required
Address *
Signing up a sibling? Please enter their name, age, gender and grade level *
Parent Guarding #1, First and Last Name
Cellphone
Address *
E-mail *
Parent Guarding #2, First and Last Name
Cellphone
Address
Clear selection
Email
Additional Emergency Contact, First and Last Name *
Cellphone *
Relationship to Child *
Additional People permitted to pick up besides parents/guardians *

Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).

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Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?

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Is your child allergic to any type of food or medication?

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Does your child require a special diet?

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I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.

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I understand that the Enriched Minds LLC will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.

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How did you hear about Enriched Minds Camp? *
Terms of Agreement:

Photo Release

I hereby give permission for my child to be photographed during the Enriched Minds LLC CAMP. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Enriched Minds LLC and its affiliates.

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The Enriched Minds LLC and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred by the deadline given on the terms and conditions page. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician). 

Please Type in Fist and Last Name

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TERMS AND CONDITIONS

Student must be in good health: Allergies and other conditions ,which might affect the health, safety or welfare of the student, must be noted on the health history form.

Lunch/Beverage: If staying for both classes, student should bring their own lunch, must not contain perishables. We do not provide refrigeration. Water and afternoon snack will be provided if staying for both classes the same day.

Payment in full for class is due at time of registration. Registration fee ($25) is non-refundable.

For families who enroll in both classes for the day, the one hour lunch hour care will be free of charge.

Cancellation After May 15th, 2023-May 30th 2023, $200 is non-refundable.

Due to our limited enrollment, starting June 1st, 2023 there are absolutely NO REFUNDS -NO EXCEPTIONS. We do not offer refunds for student's time off, missed days, family vacations, partially missed days, any medical reasons, or anything else that requires time off from the registered class.

I have read, understand and agree to the Enriched Minds LLC policies and enrollment conditions listed above.

Please type in your First and Last name

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