Participant Form

Student name:

Date of Birth:  

Address:

Phone:

Guardian Name/Relationship to student:

Email address:

Guardian Address:

Guardian Phone:

Program(s)/Services(s):

Student Goals/Additional Information to Share: (optional)

Payment

Tuition/Fees/Packages/Per Diem Rate:

Discounts & Proration:

Other Funding Source:

Amount Pending/Received:

Scheduling Requests

Please select days/times available: (if applicable)

Monday AMTuesday AMWednesday AMThursday AMFriday AM
Monday PMTuesday PMWednesday PMThursday PMFriday PM

Dates unable to attend (tuition still applies unless excused absence):

I have read the Program Policies.

Would you like to be enrolled in our monthly newsletter? YesNo

Photo/Video Release

I DoDo Not     consent to and authorize the use and reproduction by Carlisle Academy Integrative Therapy & Sports any and all photographs and any other audio/visual materials taken of     for promotional material, educational activities, exhibitions of for any other use for the benefit of the program.

Student/Guardian:

Date: