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Student and Emergency Contact Information
Student and Emergency Contact Information, Program Policies, and Photo Release
Fields marked with
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asterisks are required
Do you have more than one child registered this session?
*
No
Yes
Child's Name
*
First
Last
Child's Name #2
First
Last
Child's Name #3
First
Last
Child Date of Birth
*
MM slash DD slash YYYY
Child #2 Date of Birth
MM slash DD slash YYYY
Child #3 Date of Birth
MM slash DD slash YYYY
Child Grade
Child School
Child #2 Grade
Child #2 School
Child #3 Grade
Child #3 School
Parent Name
*
First
Last
Email
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Phone
*
In case of emergency...
Emergency Contact
*
First
Last
Relationship
Contact Number
*
Are there special considerations concerning your child of which our staff should be aware?
REFUNDS
All refund requests must be submitted in writing either in person or email.
100% refund 8 weeks prior to camp starting minus admin fee of $50.
50% refund 4 weeks prior to camp starting.
No refunds 2 weeks prior to the camp starting.
MISSED CLASSES/ABSENTEE:
Refunds are not issued for missed classes. Montclair Learning Center (MLC) generally does not offer make up classes. However, if the same class is offered on a different time/day and there is space available in the class, one make-up session per semester may be scheduled.
DISRUPTIVE BEHAVIOR
Students and instructors are expected to be respectful and courteous to each other. MLC reserves the right to request a disruptive student to leave camp and not attend any remaining sessions. If a student is asked to leave the program, class fees (less $25 administrative fee) will be refunded for any remaining sessions but not for sessions already attended.
STUDENT LIABILITY WAIVER AND PHOTO RELEASE:
By enrolling in MLC's programs, parent/guardian agrees that neither MLC nor any MLC staff member, shall be liable for any damages or injury to the student, or any other person, on the MLC premise and the parent/guardian agrees to hold MLC harmless from any claims for damages, no matter how caused. By enrolling in a MLC program or activity, parents and guardians authorize MLC and its staff to use, publish, distribute, and copyright photographs, video recordings, or other portraits or likenesses of the student, in which the child may be included in whole or in part, for lawful use on MLC's website, social media properties and printed materials, in both present editions and future editions. MLC will refrain from printing the name of the child in connection with the aforementioned likenesses, unless explicitly authroized by the parent. Parents and guardians who enroll in MLC program(s) release MLC from any claims that may arise regarding the use of the child's image, including any claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity or copyright.
PERMISSION TO PROVIDE EMERGENCY CARE:
I hereby give permission to emergency medical service personnel to order x-rays, routine tests and treatment for my child in the event that I cannot be reached in an emergency. By submitting the form, I understand that I am acknowledging that I have read and understand the terms of the program policies outlined by MLC and will adhere to the terms and policies.
Signature
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