Homeschool & Classical Learning Center Annual Intake Form

This form is valid from July through June.

Please complete this form for each child (6 years and above) you would like to participate at the center. You do not need to create separate forms for each child. After you complete the Consent/Authorization section click on the

link to add the next child's information.

Parent Contact Information

Parent First Name

Parent Last Name

Relationship Type:

Parent Mobile Phone Number

Parent Mobile Opt-In

I authorize text messages to the mobile telephone number above and accept responsibility for any charges incurred.

Parent Email Address

Mailing Address

Country

Street

City

Region

Postal Code

DeleteChild _ID_
Add Children Information Below
Child Info First Name Middle Name Last Name Birthdate Birthdate Email (if available): Mobile Phone (if available): Mobile Opt-In Mobile Opt-In I authorize text messages to the mobile telephone number above and accept responsibility for any charges incurred. Allergies: Special Needs: Concerns: School Info Are you Homeschooled: Are you Homeschooled: Yes No Do you attend a Classical School: Do you attend a Classical School: Yes No Anticipated High School Graduation Year Consent / Authorization Parental Consent: I hereby give permission for my child to take part in any HCLC event. It is acknowledged that all necessary precautions will be implemented to ensure the safety and welfare of my child. However, in the case of an accident or illness, Ashland University, its staff, and volunteers are released from any liability. Parental Consent: I hereby give permission for my child to take part in any HCLC event. It is acknowledged that all necessary precautions will be implemented to ensure the safety and welfare of my child. However, in the case of an accident or illness, Ashland University, its staff, and volunteers are released from any liability. Yes No Marketing Media Authorization: I acknowledge that during this programming, my child may have their image and/or voice captured through photo, audio or video recording. I irrevocably consent to and authorize Ashland University and its affiliates, agents, successors and assigns to use the videotape and photographs of my child, and recordings of his/her voice, conversations, sounds, name, image and likeness in all types of media and for all lawful purposes. I hereby waive any right of inspection or approval of the use of my child’s voice, conversation, sounds, image and likeness. I acknowledge that Ashland University will rely on this grant of rights and hereby agree not to assert any claim of any nature whatsoever against anyone relating to the exercise of the rights granted hereunder. Marketing Media Authorization: I acknowledge that during this programming, my child may have their image and/or voice captured through photo, audio or video recording. I irrevocably consent to and authorize Ashland University and its affiliates, agents, successors and assigns to use the videotape and photographs of my child, and recordings of his/her voice, conversations, sounds, name, image and likeness in all types of media and for all lawful purposes. I hereby waive any right of inspection or approval of the use of my child’s voice, conversation, sounds, image and likeness. I acknowledge that Ashland University will rely on this grant of rights and hereby agree not to assert any claim of any nature whatsoever against anyone relating to the exercise of the rights granted hereunder. Yes No Marketing Communication Authorization: By providing my contact information, I agree to receive marketing and promotional communications from Ashland University via text message and/or email. I understand that message and data rates may apply and message frequency may vary. Marketing Communication Authorization: By providing my contact information, I agree to receive marketing and promotional communications from Ashland University via text message and/or email. I understand that message and data rates may apply and message frequency may vary. I consent to receive marketing and promotional communications from Ashland University.

Add Additional Children

Emergency Contact
Please list the name and phone number of the individual you would like us to contact if you are not available.

Name:

Phone Number