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First Name*

Last Name*

Email Address

Phone Number*

Date of Birth*

Gender* FemaleMale

First Name

Last Name

Home Address

City*

State*

Zip Code

Country

Parent Email

Home Number

Cell Phone Number

First Name

Last Name

Phone Number

List Allergies/Medical Problems or Dietary restrictions

Liability Release

I release all liability from the Community Outreach Coalition and all its programs in case of a injury or damage of property/equipment. I will take responsibility for injury or damages caused by my child during the programs hosted by the Community Outreach Coalition. YesNo

Photographs/Media Release

I authorize COC to take photographs of my child for class projects, school displays and/or publicity. YesNo

Permission for Emergency Medical Treatment

I authorize COC to obtain all necessary medical care for my child in the event of sickness or injury. YesNo

Which program are you registering for?* Senior Healthcare ServicesTutoringServing Seniors

Name of School Child Attends

Online Signature*

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