Child's name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

How would you describe your child's math ability? *

Struggling with math at school

At grade level

Advanced/beyond their grade level

Is your child receiving one-on-one support at school? *

Yes

No

Parent name *

First Name

Last Name

Phone *

(###)

###

####

Image release *

Do you permit the use of photos and videos taken of the group’s activities that include your son/daughter to be used in the program’s promotional materials (eg. brochures, Instagram)?

Yes

No

Waiver *

I hereby give permission for my son/daughter to attend this program. I understand that the Edmonds Youth Education Centre will endeavor to provide my son/daughter with a safe environment. In the case of personal injury, loss or damage I, or a third party, will not hold Edmonds Youth Education Centre, its agents or volunteers responsible.

Yes