Homeschool Program Registration Student InformationParent's Name:* First Last Parent's Name: First Last Number of children you are registering:*Please enter a number from 1 to 4.Child's Name:* First Last Child's Date of Birth:* MM slash DD slash YYYY Child's Name:* First Last Child's Date of Birth:* MM slash DD slash YYYY Child's Name:* First Last Child's Date of Birth:* MM slash DD slash YYYY Child's Name:* First Last Child's Date of Birth:* MM slash DD slash YYYY Mailing address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email address:* Enter Email Confirm Email Home Phone:*Cell Phone:*Work Phone:Best Number to Reach You:* Home Phone Cell Phone Work Phone Medical InformationPlease answer the following questions regarding your child:Does your child have any allergies? Specific dietary needs/food sensitivities? Medical conditions?*Does your 2nd child have any allergies? Specific dietary needs/food sensitivities? Medical conditions?*Does your 3rd child have any allergies? Specific dietary needs/food sensitivities? Medical conditions?*Does your 4th child have any allergies? Specific dietary needs/food sensitivities? Medical conditions?*Is your child currently taking any medications?* Yes No Please list medications:Is your 2nd child currently taking any medications?* Yes No Please list 2nd child's medications:*Is your 3rd child currently taking any medications?* Yes No Please list 3rd child's medications:*Is your 4th child currently taking any medications?* Yes No Please list 4th child's medications:*Has your child had recommended immunizations?* Yes No If not, which ones have yet to be administered?*Has your 2nd child had recommended immunizations?* Yes No If not, which ones have yet to be administered for your 2nd child?*Has your 3rd child had recommended immunizations?* Yes No If not, which ones have yet to be administered for your 3rd child?*Has your 4th child had recommended immunizations?* Yes No If not, which ones have yet to be administered for your 4th child?*Has your child had a recent vision and hearing test?* Yes No Has your 2nd child had a recent vision and hearing test?* Yes No Has your 3rd child had a recent vision and hearing test?* Yes No Has your 4th child had a recent vision and hearing test?* Yes No **Current immunizations and vision/hearing tests are strongly recommended. Records may be required for registration.Does your child have any other special needs?*Does your 2nd child have any other special needs?*Does your 3rd child have any other special needs?*Does your 4th child have any other special needs?*Person to Contact in Case of Emergency:Name* First Last Relationship to your child(ren):*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Preferred Hospital:*Name of Family Physician:* First Last Phone Number for Family Physician:*In case of emergency, do we have permission to administer CPR and/or authorize an ambulance to transport your child(ren) to a hospital?* Yes No Emergency Contact Acknowledgement:* By checking the box, you are agreeing that the information provided is accurate. Meridian Learning Photo ReleasePermission: I/We give permission for photos/videos to be taken of: Child's Name:* First Last 2nd Child's Name:* First Last 3rd Child's Name:* First Last 4th Child's Name:* First Last while he/she is participating in Meridian Learning activities. I/We understand that photos/video may be published online, in printed materials and/or for other promotional purposes, but only to help document student work and illustrate Meridian Learning programs. I/We hereby waive any ownership rights, as well as any right that I/we may have to inspect or approve the finished product in which a photographic or video image may be used including the advertising copy or other matter that may be used in connection therewith or the use to which it may be applied.Meridian Learning Homeschool Program Parent AgreementTuition*Full SessionHalf SessionTotal charge via Paypal: $0.00 Preferred Days:* Monday Tuesday Wednesday Thursday Friday Saturday Multi-sibling discount:* No Yes Confidentiality Meridian Learning is committed to protecting the privacy of all families who participate in our programs, as well as the children in the learning environment. With this in mind, we will not discuss confidential information in the presence of children or other parents. If you wish to discuss sensitive issues pertaining to your child, please schedule a time to meet with the guide/directress or contact us via phone/email. It is also important to note that we expect all parent/family visitors and guests to maintain the same confidentiality and highest level of respect for the children. Please treat each child as you would want your child treated. Parent Participation Due to the structure and format of the program, parent participation is encouraged and expected. Meridian Learning is committed to providing a quality, affordable educational option for you and your family. We are only able to offer this option only with the help of parents who agree to assist with duties such as helping with providing snack and planning field trips when offered. In registering for the program, you acknowledge that you are willing and able to give this time and assistance. Parents are also encouraged to attend parent education events if they do not attend classes. Please see the parent agreement addendum for more information regarding parent participation. Attendance/Punctuality, Inclement Weather and Make-ups Whenever possible, please give a two (2) hour notice if your child is unable to attend class. We regret that we cannot excuse you from payment or grant refunds for absences. Punctuality is expected. If parents are consistently late for drop-off/pick-up, participation in the program will be terminated. In the highly unlikely occurrence that your child’s class is cancelled due to inclement weather or illness, make-up classes will be scheduled at the end of the semester. Student Behavior We reserve the right to terminate sessions at any time should a child’s behavior/needs, consistently and beyond an initial adjustment period, impact the quality of the environment, interfere with the functioning of the class as a whole and/or endanger himself or other students. Student Information, Medical Information, Emergency Contact, Meridian Learning Photo Release & Meridian Learning Homeschool Program Parent Agreement Acknowledgement:* By signing below, you are agreeing that the information provided is accurate and that you have read the Meridian Learning Photo Release and Meridian Learning Homeschool Program Parent Agreement. My signature below indicates that I agree to all of the above provisions regarding my family’s participation in the program. Parent/Guardian Name:* First Last Parent/Guardian Signature*Parent/Guardian Name: First Last Parent/Guardian Signature