Registration | Charlotte Community

Parent/Guardian Last Name

Parent/Guardian First Name

Address

Phone Number

Secondary Phone Number

Email

Second Parent/Guardian Last Name

Second Parent/Guardian First Name

Address

Phone Number

Secondary Phone Number

Email

How did you hear about us?

If FB, any particular group?

How long have you homeschooled?

Student Last Name

Student First Name

CCC Opportunities

Discovery Steam Series(Ages 12+) Monday, July 6th 5-8 PM

Discovery Steam Series (Ages 12+) Monday, Aug. 3rd 5-8 PM

Academic Monday Co-op Year 26-27

Discovery Steam Series (Ages 7-11) Monday, July 13th 5-8 PM

Discovery Steam Series (Ages 7-11) Monday, Aug. 10th 5-8 PM

Birthday

Month

Day

Year

Does your child have any allergies/medical conditions we should be aware of? If yes, please list.

Yes

No

Allergies/Medical Conditions

Primary adult responsible for pick up & drop off?

Phone Number

Secondary adult responsible for pick up & drop off?

Phone Number

Emergency Contact

Phone Number

Second Emergency Contact

Phone Number

Student Last Name

Student First Name

CCC Opportunities

7/11 Social (Ages 7-11) Monday, June 8th 5-8 PM

7/11 Social (Ages 7-11) Monday, July 13th 5-8 PM

7/11 Social (Ages 7-11) Monday, Aug. 10th 5-8 PM

Summer Side Quests (Ages 12+) Monday, June 1st 5-8 PM

Summer Side Quests (Ages 12+) Monday, July 6th 5-8 PM

Summer Side Quests (Ages 12+) Monday, Aug. 3rd 5-8 PM

Academic Monday Co-op Year 26-27

Birthday

Month

Day

Year

Does your child have any allergies/medical conditions we should be aware of? If yes, please list.

Yes

No

Allergies/Medical Conditions

Primary adult responsible for pick up & drop off?

Phone Number

Secondary adult responsible for pick up & drop off?

Phone Number

Emergency Contact

Phone Number

Second Emergency Contact

Phone Number

I hereby consent for the child/ren above to participate in the Charlotte Community Cooperative. I hereby irrevocably grant Charlotte Community Cooperative the absolute right and permission to copyright and/or publish or use photographic portraits or pictures of my child/ren. These may be used in whole or part, composite or distorted in character or form. They may be used in conjunction with my name or a fictitious name, or reproductions thereof in color or otherwise, made through any media, art, advertising, or any lawful purpose whatsoever. I also grant Charlotte Community Cooperative the same permissions and right to use any statements for testimonials made by me.

I agree with above terms.

First and Last Name

Date

Month

Day

Year

Signature

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