8/11/2019 RES Session 1 Enrichment Registration

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*ENRICHMENT CLASSREGISTRATION *Richmond Elementary 2014 2015

Session 1: Sept 8 October 17 2:35 - 3:30Legos & Games - Tuesdays($48) K - 2ndCeltic Dance - Tuesdays ($60) 1st- 4thKitchen Science - Wednesdays ($60) 3rd- 4thCrafts for Doll/Animal - Thursdays ($50) K - 2nd

Attending Part 2 after classAttending Part 2 after classAttending Part 2 after classAttending Part 2 after class

PERSONAL INFORMATION

Childs Name: Birth Date: Grade: M / FParent/Guardians Name:Address:

Phone: C: OK to text msg? Y N H/W:E-mail:Parent/Guardians Name:Address:Phone: C: OK to text msg? Y N H/W:E-mail:

DISMISSAL PLANPlease share with us how your child will be getting home after class. If there is a change in yourchilds dismissal (ex. going home with another parent), please send your child in with a signed

note explaining this change.

My child will be picked up at 3:30 by

My child will attend Part 2 after the enrichment class.

ADDITIONAL PEOPLE THAT MAY PICK UP MY CHILD(REN) / EMERGENCY CONTACTS

Name: Phone: C: W/ H:Name: Phone: C: W/ H:

MEDICAL INFORMATION

Physicians Name: Phone:Current Medications: Allergies:Insurance Company: Policy Number:

PARENT/GUARDIAN AUTHORIZATION

Signed: Date:

Please make checks payable to: Part 2 RES

Please drop off this form with Ashley Mousley of Part 2 or scan and email toLorien Leyden at lleyden@cssu.org.

8/11/2019 RES Session 1 Enrichment Registration

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AGREEMENT AND WAIVER / RELEASE OF LIABILITY

I hereby authorize any additional medical treatment deemed necessary in the

event of emergency or injury and hereby agree to indemnify, defend and hold

harmless the above Organizers and Instructors from any and all liability, costs and

expenses on account of personal injury or property damage arising from my

childs participation in Part 2 Enrichment classes.

Do you grant permission to publish the likeness or image of your child for

enrichment classes? Yes No

Parent/Guardian:Print Name: __________________ Sign: ________________ Date: _____

SESSION 1 ENRICHMENT CLASS OFFERINGS

Legos & Games - Instructor: Mary Marcotte - TuesdaysCome learn new games and enjoy the old classics! This class is a greatopportunity to spend time with friends, practice good sportsmanship and have funafter school! We will build with Legos and games of all kinds from Chutes andLadders to Chess! Join us for a social and team building experience!Cost: $48 Grade: Kindergarten - 2nd grade

Celtic Dance - Instructor: Heather Morris - TuesdaysParticipants will explore Irish and Scottish movements including jigs, reels andeven the basics of the sword dance to lively Celtic music. This class is a wonderfulway to spend the afternoon!Cost: $48 Grade: 1st - 4th grade

Kitchen Science - Instructor: Andrea Greeley - WednesdaysIt is a time to explore the wondrous world of science with mysterious mixturesthat creep, bubble, and stretch your knowledge and thinking powers. Eachconcoction is a scientific experiment. You learn to think like a scientist and usescience safety procedures. Learn about molecules, solid, liquid and gas, lava,viscosity, goo globs, quicksand, and more!

Cost: $60 Grade: 3rd - 4th grade

Crafts for Dolls & Stuffed Animals - Instructor: Lori Mulvihill -

ThursdaysCome create accessories for your favorite doll or stuffed animal! From clothes toblankets, we will create anything your furry friend may need! Fabrics and materialssupplied to get your imagination going!Cost: $50 Grade: Kindergarten - 2nd grade