Registration

Student Last Name

Student First Name

Birthday

Month

Day

Year

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

Yes

Allergies/Medical Conditions

Parent/Guardian Last Name

Parent/Guardian First Name

Address

Phone Number

Secondary Phone Number

Second Parent/Guardian Last Name

Second Parent/Guardian First Name

Address

Phone Number

Secondary Phone Number

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

How long have you homeschooled?

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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