liability waiver – itavenrichmentcenters

Thank you for choosing ITAV Enrichment Centers! Please complete the form below so we can best serve your child’s educational and personal needs.

Student Information :

Full Name *

DOB *

Enter Age *

GenderSelect GenderMaleFemale

Start Date *

Home Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Parent/Guardian Information - I :

Name *

Relationship to Student *

Phone Number (Mobile) *

Phone Number (Work/Home)

Email Address

Mailing Address (if different)

Parent/Guardian Information - II :

Name

Relationship to Student

Phone Number (Mobile)

Phone Number (Work/Home)

Email Address

Mailing Address (if different)

Emergency Contacts (Other than Parents/Guardians)

(At least one required)

Emergency Contact-I

Name *

Relationship to Student *

Phone Number (Mobile) *

Emergency Contact-II

Name

Relationship to Student

Phone Number (Mobile)

AUTHORIZED PICK-UP PERSONS

Please list anyone (in addition to parents/guardians) authorized to pick up your child:

Person 1 Name

Person 1 Phone Number (Mobile)

Person 2 Name

Person 2 Phone Number (Mobile)

Person 3 Name

Person 3 Phone Number (Mobile)

HEALTH & SAFETY INFORMATION

Allergies (food, medication, environmental):

Allergies and Reactions

Allergen

Known Reaction

Allergen

Known Reaction

Allergen

Known Reaction

No known allergies : Medical Conditions (e.g., asthma, diabetes, epilepsy)None known : Medications taken regularlyNone

Does your child carry an inhaler, EpiPen, or other emergency medication?

YesNo

If yes, please specify

Preferred Hospital:

Primary Physician:

Physician Phone:

BEHAVIORAL & LEARNING INFORMATION

•Behavioral or learning considerations:

Acknowledgment:

CheckboxI acknowledge that my child does not exhibit violent, harmful, or extreme reactions to stressors or learning challenges that would endanger themselves or others.

Interests / Strengths:

Anything else we should know to best support your child:

Please initial each statement:

CheckboxI grant permission for my child to participate in ITAV activities and enrichment programs.I grant permission for ITAV staff to seek emergency medical care if I cannot be reached.

CRITICAL THINKING & CURRENT EVENTS WAIVER

ITAV Enrichment Centers teaches critical thinking and encourages discussion of real-world events. As part of the curriculum, staff may mention or discuss recent political events or current issues.

We approach every topic from a Christian conservative perspective. Students will be constantly challenged to defend and support their arguments, even on points where staff or peers may agree with them personally. Our role is not to replace parental guidance, but to guide students in forming opinions and reasoning whether they agree with our personal Christian conservative standpoint or not. Every student will be respected throughout this process. We do not have to agree to have mutual respect.

Attending ITAV means you acknowledge and accept that such discussions and challenges will occur. Our goal is to spark reflection and meaningful dialogue within your family.

Parent/Guardian Signature: *

Date *

ITAV Enrichment Centers – Student Registration Form

Thank you for choosing ITAV Enrichment Centers! Please complete the form below so we can best serve your child’s educational and personal needs.

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