Student Name (required)
Birch HillAmherst StBicentennialDr. CrispMain DunstableNew SearlesMt. PleasantHome SchoolOther
Would you like to have a high school student tutor practice with your 3rd to 5th grade student one day per week
Yes for a tutorNo for a tutor
Primary Contact Name
Lessons or performances might be photographed or videotaped with the intent to publish on our website, facebook page or utilize in grant applications.
Permission to use photograph YesPermission to use photograph No
Permission to use child's name with photography.
Permission to use name YesPermission to use name No
I HEREBY AUTHORIZE ANY LICENSED PHYSICIAN, HOSPITAL, CLINIC OR OTHER MEDICAL FACILITY TO HOSPITALIZE AND SECURE PROPER TREATMENT FOR MY CHILD NAMED ABOVE
Please enter your Health Insurance Provider