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WHO WE ARE
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GiftedAcademy
GiftedImpact
GiftedSummer
GiftedReach
ImpactReport
THE VILLAGE
Our Culture + Space
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GiftedImpact Enrollment
Enrollment Form
GiftedImpact Enrollment Form
Student Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
School Site
*
Barwell Road Elementary
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Grade
T-Shirt Size
*
Youth S
Adult S
Adult M
Adult XL
Adult 2XL
Please explain any of your child's special needs?
Background/Ethnicity
*
Asian/Pacific Islander
Black/African-American
Caucasian/White
Latin/Hispanic Origin
Native American/American Indian
Parent/Guardian Information
Primary Parent/ Guardian
*
First Name
Last Name
Relationship to child
*
Does child live with this individual?
*
Yes
No
Part-time
Email
*
Preferred method of contact:
*
Home phone
Cell phone
Email
Text
Parent Phone
*
(###)
###
####
Does your child have allergies, special diets, or medications?
*
Yes
No
If yes, please list/describe:
Does your child have any additional needs?
*
Yes
No
If yes, please describe:
Does your child have any serious medical conditions?
*
Yes
No
If yes, please describe:
Emergency Contact Information
The emergency contact should not be the same as primary parent/guardian.
Emergency Contact Name 1
*
First Name
Last Name
Emergency Contact Phone 1
*
(###)
###
####
Do you give permission for your child to be released to this person?
*
Yes
No
Parent Consent/Release Form
I certify that my child who is hereby enrolled in TheGifted Arts, Inc. with this agreement, is in excellent health and may participate in the physical activities associated with the TheGifted Arts Program. I represent that my child has insurance through my own or an alternative insurance carrier. I understand that each participant must assume the risk and related financial responsibility that could result from participation in any activities. I agree to assume any risk and financial responsibility.
*
Agree
Disagree
Pictures / Media (Please check one)
*
Do you grant permission to TheGifted Arts, Inc. to use pictures and video(s) of your child in any promotional material, as well as to post on TheGifted Arts Inc. website and/or social media outlets.
I grant Permission
I DO NOT grant Permission
Data /Surveys (Please check one)
*
We are seeking permission to occasionally survey enrolled members to measure student growth and program satisfaction.
I grant permission
I DO NOT grant permission
Thank you!
Your enrollment form has been received.
You should receive a confirmation email shortly.