Pop Up Clubs And Activities

Student Name(Required)

First Last

Homeroom Teacher/Grade(Required)

Allergies or Health Concerns? (If none, please put N/A)(Required)

Pop-Up Choice # 1(Required)

Pop-Up Choice # 2

Pop-Up Choice # 3

Pop-Up Choice # 4

Parent Name(Required)

First Last

Parent Email(Required)

Parent Contact #(Required)

Parent 2 Name

First Last

Parent 2 Contact #

Parent 2 Email

Emergency Contact Name(Required)

Emergency Contact #(Required)

Student Pick-up(Required)

Student Pick-Up Other

Payments will be all done through FACTS. Should this be an issue please email Jessica Mahfoudi:(Required)

I understand I will be billed via FACTS

By registering my child(ren) for the above program, I, (Parent/Guardian Name), agree to participate or allow my child(ren) and family members to participate and hereby release St. Martin’s in-the-Field Episcopal School, its directors, officers, agents, coaches, parents, and employees from liability for any injury that might occur to myself (or to my child(ren) and family members) while participating in the program. I agree to indemnify and hold harmless the above-mentioned organizations and/or individuals, their agents and/or employees, against any and all liability for personal injury, including injuries or damage to my property, the property to my child(ren), and/or other family members, or both, while participating in the program.

Signature

Note: In the event that activities are canceled, funds will be applied to the next session of clubs and activities.

This field is for validation purposes and should be left unchanged.

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