L.E.A.D. Academy Summer Cub Care

Registration Form

Please fill out the following form as completely as possible.

$25 Registration fee and weekly/daily charges may be paid on Gradelink or in person in the main office.

Student Information

Student's Full Name

Address

Parent 1 - Full Name

Parent 1 - Phone Number

Parent 1 - Email

Parent 2- Full Name

Parent 2 - Phone Number

Parent 2 - Email

Full Name

Phone Number

Full Name/Relationship to Student

Does your student have allergies that we should be aware of?

Yes

If yes, please list the allergy here:

Does your student use either of th following?

Inhaler

EpiPen

Student Name

Parent/Guardian Signature -- by typing your name you agree to the above statements.

Check this box if you do NOT consent to your student being photographed or videod.

Student Name

Parent/Guardian Signature -- by typing your name you agree to the above statements.

Thanks for submitting!