Registration & Insurance Form

STUDENT INFORMATION

Student Name: Age: Date of Birth:

Sex: Male Female Grade: School Attending:

Parent / Guardian Name: Address:

City/State: Zip: Phone:

Mobile: Email:

Academic Concerns:

PRIMARY PHYSICIAN

Name:
Address:
City:
State:
Phone:

HEALTH INSURANCE CARRIER

Name:
Group Number:
Policy Number:
Phone:
(NOTE: Health insurance information needed in case of required emergency medical care)

ALLERGIES, MEDICATIONS or PRE-EXISTING CONDITIONS

Enter here:

AFTER-SCHOOL PROGRAM / TUTORING INFORMATION

After-School Program
Full-Time
Part-Time (specify days attending):

Monday Tuesday Wednesday Thursday Friday

Academic Tutoring
Monday - Time:
Tuesday - Time:
Wednesday - Time:
Thursday - Time:
Friday - Time:
Saturday - Time:

Pick-Up from School Requested: Yes No
If Yes, Student Pick-Up Time:

Authorized Person(s) to Pick-Up Student from The Character Center:
Name:   Relationship to Student:
Name:   Relationship to Student:
Name:   Relationship to Student:

PARENT / GUARDIAN CONSENT

By submitting this form below, I agree that I am the parent or legal guardian of the student named above, and I grant permission for my child(ren) to participate in program activities provided at The Character Center. I understand that Pivotal Point Enterprises, Inc. will not be responsible for injuries or loss. I release and hold harmless and will not hold legally responsible Pivotal Point Enterprises, Inc, its officers, agents, contractors, subcontractors, or employees with respect to any and all such injury or loss. If I cannot be reached in the case of emergency, or immediate medical care is required, I do hereby authorize a physician selected by Pivotal Point Enterprises, Inc. to administer emergency treatment including medications, diagnostic tests, surgery, or other medical intervention deemed necessary by the physician. I further agree to the fee schedule for program services, and acknowledge that there is not a refund for late arrival or early departure from The Character Center, or if my child is dismissed due to disciplinary problems. I also allow the publication of any photos or videos taken of my child(ren) during the period he/she is in attendance at The Character Center.

Name: Relationship to Student: