Registration Form

(download this form here)

Parent’s Names (or Tutor) ____________________________________

Home Number _________________Cell Phone ___________________

Mailing address  ____________________________________________ 

                           ____________________________________________

Email address  _____________________________________________

Emergency Contact _________________________________________

       (Name, relationship, phone number)

Social Security # (tutors only) __________________________________

Health Issues/Concerns (tutors only _____________________________

______________________________________________________________

Church  ______________________________________________________

I understand that in order for the successful administration of this program, I will be expected to contribute or volunteer in a minimal capacity.  This does not apply to those who are tutors with no children attending.  I understand that the facility used by CHA will not provide general liability coverage for this Academy or its members for claims that were the result of negligence.  I will not hold program coordinators, leaders, or tutors responsible for damage, loss, or injury occurring to myself or my family members, or children in my care as a result of participation in this program.

Signature: ________________________________ Date:__________________

Non-refundable registration fee of $300 ($100 will be applied to the first month’s tuition) must accompany this registration form.

I would be interested in teaching next year.     Yes_______ No________

If yes, I have an interest in teaching ______subject and_______ grade.

I would be interested in working in the nursery. Yes ______ No ______

I give my permission for my child(ren) to be included in photographs that may be used on the CHA website, or other presentations to the public.

Yes ________    No __________

Christiana Homeschool Academy does not discriminate on the basis of race.