2019 Kid’s College
REGISTRATION FORM
Parents or Legal Guardians: Please complete the following information. Submit one form per person.
Duplicate this form as needed.
For safety reasons, completed emergency information must accompany the registration.
ECTC reserves the right to delay the registration until emergency information is provided.
Date of
Birth
Last 4 Digits
of SS#
Grade entering
Fall 2019
Last First MI
Address City State ZIP
Home Phone Work Phone Alt. Phone (Cell)
Name of Legal Guardian
Do you check
email?
Yes
No
Email
This data is optional and condential.
Female Male
White
Black or African American
Hispanic or Latino
Asian
American Indian or Alaskan Native
Native Hawaiian or Pacic Islander
Other
Date Time Title of Course Amount
Enclosed is my check/money order made payable to ECTC. Charge to Visa/Master Card/Discover/American Express.
Card No. Exp. Date
Signature of Card Holder
Emergency Information
Student’s Name Grade Date of Birth
Legal Guardian Relationship Phone
Address if different from student
Address Phone
Child’s Doctor Address Phone
Doctor’s Hospital Afliation
Medical Information
Please describe symptoms and prescriptions
While we strive to provide a safe environment, we cannot control what your child will come in contact with because of our open environment. I agree to indemnify
and hold harmless ECTC, its ofcers, agents and employees for any loss or injury that my child, __________________________________, may sustain while
participating in the Kid’s College program. In case of emergency, I ask ECTC to contact an adult listed above. If ECTC is unable to reach one of us, I authorize
ECTC to secure emergency medical treatment for my child. I understand ECTC will not administer medication to my child. Please sign and date below. My
signature also indicates my consent for my child to be photographed or videotaped for promotional purposes. I do not expect compensation when ECTC photos
are taken in the learning environment.
Signature Date
NOTE: Please see back for additional information.
