Full Registration — Pixel Code Classroom

Pixel Code Classroom After School Program

Parental Consent

Please read carefully.

I, the parent/legal guardian do hereby consent to my child's participation in the Pixel Code Classroom After School Program. I understand that this program may involve physical and creative activities.

I acknowledge that while all reasonable safety measures will be taken, participation in such activities involves certain inherent risks. I release and hold harmless Pixel Code Classroom, its staff, agents, and volunteers from any liability for injury or harm that may occur during participation in this activity.

In the event of an emergency, I authorize Pixel Code Classroom to seek medical treatment for my child as deemed necessary.

REGISTER

Location and Time

Student Name

First Name

Last Name

Student Age

Student Grade

Parent / Guardian Name 1

First Name

Last Name

Parent / Guardian Name 2

First Name

Last Name

Phone 1

(###)

###

####

Phone 2

(###)

###

####

Address

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Special Needs

Or allergies and anything else we should know.

Parental Consent

I acknowledge and accept the conditions of the liability waiver.

Payment

I will send an e-transfer payment of $400/$360 for Manor Park Public School or $450/$400 for Rockcliffe Park Public School to sunny@pixelcodeclassroom.com to complete the registration for the Pixel Code After School Program.