Mail this form with a check made payable to CSM.
PAYMENT MUST ACCOMPANY THIS REGISTRATION.
MAIL TO:
COLLEGE OF SOUTHERN MARYLAND, CONTINUING EDUCATION (REG)
PO BOX 910, LA PLATA MD 20646-0910
STUDENT’S SOCIAL SECURITY NUMBER* or STUDENT ID # DATE
(*Providing a social security number in connection with a continuing education course is voluntary.)
CHILD’S LAST NAME CHILD’S FIRST NAME CHILD’S MIDDLE INITIAL CHILD’S DATE OF BIRTH (month/day/year)(required)
HOME ADDRESS
CITY COUNTY STATE ZIP CODE
DAY TELEPHONE ((area code) number) EXT. EVENING TELEPHONE ((area code) number) EXT.
EMERGENCY CONTACT PERSON EMERGENCY TELEPHONE ((area code) number)
E-MAIL ADDRESS
HAS THE ABOVE INFORMATION CHANGED SINCE THE LAST TIME YOU REGISTERED FOR CLASSES? YES NO
The College of Southern Maryland collects information on our students’ birth date, gender, ethnicity and citizenship which is used for reporting
purposes only in compliance with the Maryland Higher Education Commission and U.S. Department of Education.
GENDER: MALE FEMALE
ARE YOU OF HISPANIC OR LATINO ORIGIN? YES NO
WHAT IS YOUR RACE? SELECT ONE OR MORE. WHITE BLACK OR AFRICAN AMERICAN
ASIAN AMERICAN INDIAN OR ALASKAN NATIVE
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
RESIDENCY: CALVERT COUNTY CHARLES COUNTY ST. MARY’S COUNTY
OTHER MD COUNTY OUT OF STATE
ARE YOU A U.S. CITIZEN? YES, I AM A U.S. CITIZEN/U.S. NATIONAL
NO, BUT I AM AN ELIGIBLE NONCITIZEN
TYPE ALIEN REGISTRATION NUMBER
NO, I AM NOT A U.S. CITIZEN NOR AN
ELIGIBLE NONCITIZEN
IMMIGRATION VISA TYPE IMMIGRATION VISA NUMBER
The information I have provided above is accurate. I understand that I am financially responsible for all charges that I incur at CSM and that
the Student Code of Conduct (available from the Student Life Department) applies to all CSM students. I will follow all of the college’s policies
and procedures. When registering for WFS or youth courses, I understand that I (or my parent or guardian if I am less than 18 years old) will
be required to sign a Statement of Informed Consent, Assumption of Risk and Release Form, and/or a health status questionnaire prior to my
(or my child’s) participation in the activity. Based upon the results of the health status questionnaire, a medical release may be required prior to
participation. I also understand that, in the event of an emergency, the college will contact emergency services to arrange transport for me (or
my child) to a nearby health-care facility.
SIGNATURE OF APPLICANT DATE (month/day/year) SIGNATURE OF PARENT OR GUARDIAN DATE (month/day/year)
(IF APPLICANT IS UNDER 18 YEARS OF AGE)
CSM Continuing Education
KIDS’ AND TEEN COLLEGE REGISTRATION FORM
CHILD’S NAME CHILD’S DATE OF BIRTH (month/day/year)
Please use this section to enter course information.
CSM Kids’ and Teen College Registration Form (Page 2)
Statement for prospective students: The College of Southern Maryland makes several federally required reports and statistics available for prospective students. The
Campus Public Safety Report contains college policies regarding a variety of safety and security issues and includes crime statistics for the college. This report is available at
ready.csmd.edu. The college also maintains a report addressing participation rates by students in intercollegiate athletics, coaching staffs, and certain expenses associated with
intercollegiate athletic teams. Both reports may also be obtained by contacting the Registrar’s Office, located in the AD Building on the La Plata Campus and at 301-934-7588.
NONDISCRIMINATION POLICY
The College of Southern Maryland does not discriminate on the basis of race, color, national origin, gender, disability, age, sexual orientation, religion, or marital status in
its programs or activities. The academic support/ADA coordinator, Disability Support Services—La Plata Campus, Learning Resource Center (LR Building), Room 123,
301-934-7614—has been designated to handle inquiries regarding discrimination on the basis of disabilities. The associate vice president, Institutional Equity and Diversity—
La Plata Campus, Campus Center (CC Building), Room 208A, 301-934-7658—has been designated to handle all other discrimination inquiries.
ADA STATEMENT
Individuals with disabilities who require special accommodations in order to participate in the college’s instructional programs should notify the academic
support/ADA coordinator at 301-934-7614 at least one month before the class begins. Requests made after this deadline will be considered on an individual
basis and addressed whenever possible.
SUBJECT COURSE NO. SECTION NO. COURSE TITLE BEGIN DATE COURSE
TUITION
RESIDENCY
FEE*
COURSE
FEE
TOTAL
AAY 8000 42123 SAMPLE 7/5/13 $XX
*RESIDENCY FEE: Maryland residents living outside of Charles, Calvert, and St. Mary’s counties—
add $5 to course fee listed, out-of-state residents-add $10 to course fee listed.
TOTAL
SCHOOL INFORMATION
I authorize the release of ’s grade level to the College of Southern Maryland. This information
is needed to verify past or current enrollment in honors, gifted and talented, advanced placement, accelerated
courses, or above- grade-level courses. This information will be submitted to the Maryland Higher Education
Commission along with other enrollment data.
School Currently Attending: Current Grade Level:
Student Information and Parent Consent
EMERGENCY CONTACT INFORMATION
MOTHER’S/GUARDIAN’S NAME
HOME PHONE WORK PHONE CELL PHONE E-MAIL
FATHER’S/GUARDIAN’S NAME
HOME PHONE WORK PHONE CELL PHONE E-MAIL
CHILD’S NAME CHILD’S BIRTHDATE
My child has my permission to be photographed, interviewed, or videotaped
while attending Kids’ College and/or Teen College classes.
PHOTOGRAPHY AUTHORIZATION
Yes No
In an emergency contact:
In addition, check off boxes next to the two contacts with permission to pick up your child if you can not be
reached (Limit - Two):
Name: Relation to Child
Home phone: Work Phone: Cell Phone:
Name: Relation to Child
Home phone: Work Phone: Cell Phone:
Name: Relation to Child
Home phone: Work Phone: Cell Phone:
Name: Relation to Child
Home phone: Work Phone: Cell Phone:
Camper's Physician Name: Phone Number:
CSM Kids’ and Teen College Registration Form (Page 3)
Student Information and Parent Consent (continued)
POLICY INFORMATION
1. I understand that disruptive or inappropriate behavior will not be tolerated and may result in dismissal
without refund.
2. I will not have my child arrive on campus earlier than 10 minutes prior to the start of class unless
accompanied at all times by a parent or legal guardian. THERE IS NO SUPERVISION FOR YOUR CHILD PRIOR
TO THIS TIME; PARENTS ACCEPT FULL RESPONSIBILITY FOR THEIR CHILD’S BEHAVIOR AND SAFETY.
3. Students must be signed out promptly after their classes at the designated drop-off area. If you are more than
15 minutes late, a $30 late fee per child will be charged for emergency drop-in care until 6 p.m.; after that,
it will be an additional $1 per minute. CSM reserves the right to request your child be removed from class, if
parents are persistently late for pickup. If we ask you not to bring your child back, you will not receive a refund.
I have read and completed the above information and permit my child to attend Kids’ or
Teen College at the College of Southern Maryland.
PARENT OR GUARDIAN SIGNATURE DATE
CHILD’S NAME CHILD’S BIRTHDATE
MEDICAL INSURANCE
HEALTH INFORMATION
NAME OF INSURER/COMPANY GROUP OR POLICY NUMBER
All campers must be current on all immunization.
Is the student currently enrolled in a Maryland public or private school? Yes No
If yes, provide school name
If no, provide copy of immunization conrming that the child has received all immunization as
required by the Maryland DHMH Recommended Childhood Immunization Schedule.
Is the student exempt from any immunization on medical or religious grounds? Yes No
If yes, provide a signed copy of Maryland Dept. of Health and Mental Hygiene Immunization
Certicate from either a licensed physician indicating that the immunization is medically
contraindicated or the parent/guardian indicating that he/she object to immunization for religious
reasons. If no, you must provide documentation as described in #1.
Allergies Is it life threating?
Bee Sting Yes No
Peanuts/Other Nuts Yes No
Other Yes No
Please tell us what medications your child is currently taking.
Please provide any additional information useful to teachers and staff at CSM.
Tell us about any medical, behavior or emotional conditions:
Asthma
Emotional issues
A.D.D.
Epilepsy/Seizures
Diabetes
Hearing Impairment
CSM Kids’ and Teen College Registration Form (Page 4)
I have registered for Summer Kids’ or Teen College classes sponsored by the College of
Southern Maryland.
I understand that participation in this activity/course involves inherent risks of injury, and that the nature of
the risks may vary depending upon the type of activity, instructor, and my own physical condition and conduct. I
also understand that it is not possible to specically list each and every individual risk, but that most courses and
activities may involve risks associated with strenuous exercise, as well as risks from the usage of equipment or
participation in group activities. I acknowledge that I will either ask for or have been given any information that I
need to determine the general risks associated with this course/activity.
I understand that I will complete a written self-evaluation of my health status to help determine whether I must
seek a physician’s permission before participating in this course/activity, but that it is ultimately my responsibility
to determine whether I can safely participate in this course/activity. I understand and agree that if the college
determines, based upon the results of the initial evaluation, that a medical clearance is necessary, that I will not
be allowed to participate in any physical activities that are part of this course/activity until I have consulted with
my physician and obtained written permission.
I understand that certain precautions may be advised for the particular course/activity. I agree to follow those
precautions and to conform to all rules and policies of the department, the instructor, and any other sponsor
of this course/activity. However, I recognize that these precautions will not eliminate the risks inherent in this
course/activity.
I voluntarily assume all risks of loss, damage, illness, or injury which I may sustain while participating in this
course/activity, including travel and usage of or any equipment or facilities. I will make no claim against and
release, waive, discharge, hold harmless and indemnify, on behalf of myself, my personal representative and my
heirs, the College of Southern Maryland and its ofcers, agents, and employees for any and all claims and causes
of action for any injury or loss, or for damages, costs, expenses, or compensation that may occur during or result
from my participation in this course/activity, whether arising through the negligence, omission, default, or other
action of any person or event associated with this course or event, including fellow participants.
I agree that all disputes, controversies, and claims that may arise between myself, my personal representative
or my heirs and the College of Southern Maryland or its ofcers, agents and employees relating to or arising out
of this Statement of Informed Consent, Assumption of Risk, and Release (including but not limited to disputes,
controversies, and claims related to or arising out of the activity set forth above) will solely be resolved by nal
and binding arbitration administered by the American Arbitration Association. Except as may be required by
law, neither a party nor an arbitrator may disclose the existence, content or results of any arbitration hereunder
without the prior written consent of both parties. Judgment on an award rendered by an arbitrator may be
entered in any court having jurisdiction thereof. My agreement to nal and binding arbitration shall in no way be
construed to limit any other provision of this Statement of Informed Consent, Assumption of Risk, and Release.
I have read and understand the above information. I give my permission for my child to participate in this course/activity and
grant the same informed consent, assumption of risk, and release on behalf of myself, my child, and the child’s family.
College of Southern Maryland
Statement of Informed Consent,
Assumption of Risk, and Release
LAST NAME FIRST NAME MIDDLE INITIAL DATE OF BIRTH (month/day/year)
HOME ADDRESS
CITY OR TOWN COUNTY STATE ZIP CODE
PARENT OR GUARDIAN SIGNATURE DATE
CSM Kids’ and Teen College Registration Form (Page 5)
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