Student Name/s and Date/s of Birth:


Parents’ Names: ______________________________________________________Home Phone __________Mother’s Cell____________ Father’s Cell_____________Address________________________________________________________________________________________________________________________________________________ The above provided information is correct and complete to the best of my knowledge.We have read and understand the terms, policies and requirements that each teacher has established for their classes and understand that signing this agreement confirms compliance. We give complete authorization for a representative of ANCHOR Homeschool of Southshore to request and receive any medical treatment for the above named child/children in the event of need. We accept full responsibility for the payment of all medical services provided. We release and hold blameless the volunteers, teachers and Board of Directors of Anchor Homeschool of Southshore from any and all claims of liability past, present and/or future. We accept the financial responsibility for any and all damage to facilities or personal property for which our Child is found to be responsible. I/We understand that the total fees must be paid at the time of registration. I/We understand that any and all deposits, fees and/or tuition amount paid is non-refundable even should the student not attend, or be expelled. I, as a Parent/Guardian of the above named child/children agree to the terms of this Agreement.Parent: X _____________________________________________ Date: ___/_____/_____Name ( Printed ) _______________________________Subscribed to and sworn before me this ______ day of ______________, 20____ by___________________________________________________ who is known to me. (Stamp/Seal)Notary Signature