Student Enrollment Student's Name * First Name Last Name Student's Date of Birth Name of Parent/ Guardian #1 First Name Last Name Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Phone (###) ### #### Email Name of Parent/Guardian #2 First Name Last Name Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email Name/Phone/Email of Emergency Contact #1 List in order of priority (including parents) whom we should contact. Include at least one person authorized to pick up your child if parents cannot be reached. Name/Phone/Email of Emergency Contact #2 Name/Phone/Email of Emergency Contact #3 Name/Phone/Email of Emergency Contact #4 The following people have permission to pick up your child from school: Medical Information and Treatment Authorization Physicians Name and Address: First Name Last Name Phone (###) ### #### Medical Alert (if any, including allergies) Has the child been prescribed an EpiPen? Medications taken by child? I hereby authorize Back to Earth School to provide first aid and obtain medical treatment for my child. In the event of an emergency every attempt will be made to contact the parents. First Name Last Name First Name Last Name Please list any medications and/or homeopathic remedies that you give permission for your child to take: Photo Release I hereby grant Back to Earth School permission to use my child’s photograph/video image. I hereby do NOT grant Back to Earth School permission to use my child’s photograph/video image Parent/Guardian #1 Signature First Name Last Name Parent/Guardian #2 Signature First Name Last Name Thank you for completing the enrollment form. We’re honored to welcome your family to Back to Earth School. Our team will review your submission and follow up with next steps soon. We're so glad you're here. Parent/Guardian Waiver Child's Name * First Name Last Name Parent/Guardian #1 Name First Name Last Name Parent/Guardian #2 Name First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### I, the parent (or guardian) of the child listed at the top of this agreement acknowledge that certain reasonable risks exist in sending our child to Back to Earth. I am aware of the types of activities in which the child will be participating during his/her time at school and have been given ample opportunity to ask any questions which I may have about the environment the child will be in and the activities he/she will participate in. I acknowledge that the educational approach at Back to Earth provides a different educational experience from that offered by traditional schooling and we are willing to assume risks inherent in this choice if risks are found to exist. Carlie Khodabakhsh and Back to Earth School llc, should not be responsible for injuries to this child, unless resulting from gross negligence, while the child is in the care of a teacher. As parent (guardian), I hereby release and discharge the school and its teachers from all liability. Parent/Guardian #1 Signature First Name Last Name Parent/Guardian #2 Signature First Name Last Name Thank you!