Personal Information - Parent/Guardians *

Primary Parent/Guardian

First Name

Last Name

Primary Phone *

Country

(###)

###

####

Secondary Phone

Country

(###)

###

####

Emergency Contact *

First Name

Last Name

Primary Phone *

Country

(###)

###

####

Participant Name *

Full Name

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

Enter the date of birth of the Participant.

MM

DD

YYYY

Participant's Address *

This section is required.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What subject(s) does the student require help in?

Select all that apply

Math

English

Sciences

Social Studies (History, Geography)

Other (please specify under "additional information")

Does the student have an IEP (independent education plan)? *

Yes

No

Will the student be picked up from the program? *

The student will not be picked up from the program. By checking this box, I agree that the student is of appropriate age to get themselves home safely by themselves.

The student will be picked up from the program.

Full name of individual picking up the student

First Name

Last Name

Phone

What is the contact information of the individual picking up the child?

Country

(###)

###

####

I give consent for Bartley Skills Development Program to take photographs, videotapes, or make digital recordings of myself/my child. I hereby acknowledge that Bartley Skills Development Program will use program footage, including still photographs and video images for promotional purposes only. *

Yes

No

Waiver on Activities *

I agree that as a parent/guardian of a child/participant who is registered in the Bartley Skills Development Program, I/my child will participate in activities that may be physically challenging. I am aware of the risks and hazards associated with this camp. I agree that Bartley Skills Development Program, its trustees, officers, directors, employees, agents, and independent contractors, shall not be liable for any injury to myself/child or any loss/damage to my personal/child’s property arising from, or in any way resulting from my own/my child’s participation in these activities.

I do