Registration - SOLH Academy

Select Your Program:

Child's Name:

First

Last

Street Address:

City:

State:

Zip Code:

Guardian's Name:

First

Last

Phone Number:

Guardian Email

Child's Gender:

Male
Female
Other

Child's Birthday:

(MM/DD/YYYY)

Child's Race:

Child's Country of Origin:

Is the Child Proficient in English?

Yes
No

Other Languages Spoken in the home:

Grade Level:

School Atending:

Does the Child have Health Insurance?

Yes
No

Does Child have any Documented Disabilities?

Yes
No

if yes, Identify Disabilities:

List child's dietary restrictions:

In the event no one can be contacted I give permission for my son or daughter to receive emergency medical treatment

Yes
No

By selecting yes, you are consenting that you understand that every effort will be made to reach you for instructions if my child should become ill or injured while on the site or on a field trip. If in the judgment of the staff or a medical professional, delay in reaching you might jeopardize the child’s well-being, I herby authorize the staff or medical professional to secure whatever medical treatment is deemed necessary, including the administration of anesthetics and surgery.

If you would like for us to follow a different emergency/medical procedure, please write it/ explain it below.

List all of your child's allergies:

Child's Insurance Company and Policy:

Child's Primary Doctors Name and Number:

Child's for Does

List legal guardians name if other than mother and father:

Emergency Contacts: List full names, telephone numbers, email addresses and relationship to child.

Family Status

Guardian Consent:

Yes
No

By submitting this form, I agree and certify to the following: 1.) I acknowledge that the application information and medical information I have provided above is true and complete to the best of my knowledge and ability. 2.) I understand that participation by my children in SOLH may involve classroom education, some physical education, meals, and offsite field trips. As these activities may carry some degree of risk to my child’s physical and emotional health, I hereby release, hold harmless and release all claims associated with SOLH, the program site, all employees, officers, directors, agents, volunteers and partners of SOLH. 3.) I agree to make every effort to ensure that my child participates in the program on scheduled days, unless he/she it too ill to attend. 4.) I agree to all the program standards. I am aware there may be additional fees, to be paid prior to securing of needed texts/supplies or outings.

Registration FEE of $50 paid:

Yes
No
Waived

Payments to be made via: Zelle to “solhone@gmail.com” or PayPal (PayPal.me/SonsofLittleHaiti)

Register for a SOLH Program

PAYMENT LINKS: