EmailMe Form - Sunshine's Heart Academic Enrichment Program

Program Location *

STUDENT INFORMATION

Student's Name

First Last

Gender *

Date of Birth *

MM / DD / YYYY

Age *

2025-2026 Grade Level *

School District

Current School *

School District

Student ID Number *

Your student ID number can be found on his/her report card. If you do not know your child's ID #, please enter please enter 000-0000.

T-Shirt Size *

Student's Home Address *

Street Address City State / Province / Region Postal / Zip Code

Primary language spoken in home *

Race/National Orgin *

Does the student have a documented disability? *

Yes

No

If YES, you MUST provide supporting documentation and complete the next three questions. If No, Please proceed to Parent/Guardian Information.

Upload Supporting Documentation

If yes, do you have

an Individualized Education Plan (IEP) from the school system

a Section 504 Plan

a medical diagnosis from a doctor

other

If you answered yes to the above, how would you best classify the type(s)?

PARENT/GUARDIAN INFORMATION

Who does the child live with?

Parent/Guardian 1 *

First Last

Relationship *

If Parent/Guardian address is the same as the student's address, please leave blank.

Street Address City State / Province / Region Postal / Zip Code

Mobile Phone *

### - ### - ####

Work Phone

### - ### - ####

Email *

Parent/Guardian 2

First Last

Relationship

If Parent/Guardian address is the same as the student's address, please leave blank.

Street Address City State / Province / Region Postal / Zip Code

Mobile Phone

### - ### - ####

Work Phone

### - ### - ####

Email

EMERGENCY CONTACT INFORMATION

Full Name *

First Last

Relationship to Student *

Mobile Phone *

### - ### - ####

Work Phone

### - ### - ####

Is the above person authorized to pick-up child? *

Yes

No

TRANSPORTATION INFORMATION

Mode of transportation *

If needed someone from our team will contact you with additional information.

Is transportation needed? *

If needed someone from our team will contact you with additional information.

If private bus service, please provide the name and number for the service provider.

HEALTH INFORMATION

All health conditions including allergies MUST be disclosed to ensure student safety.

Are there any medical conditions or behavioral problems? *

Yes

No

If yes please explain

Does your child have any allergies (food, nuts, etc.)? *

Yes

No

If yes please list allergies

Are there any activities the child may not participate in? *

Yes

No

If yes please list activities

Are there any areas your child may need additional support in? *

Yes

No

If yes, please explain below:

CONSENTS AND DISCLOSURES

I understand that there is a one-time registration fee of $50.00 for the 2025-2026 Academic Enrichment Program. I understand that this fee is non-refundable and must be paid at the time of registration. *

I understand & agree

I understand that invoices (if applicable) are due on Friday for the week ahead and that failure to submit payment by 5:00pm on Sunday will result in a late fee of $10.00 and $5.00 each day after.

Failure to pay by 5:00pm on Tuesday will result in the suspension of programming until the balance is made current. *

I understand & agree

I understand that this an Academic Enrichment Program and while homework assistance and tutoring will be provided daily, it is my child's responsibility to complete any homework assignments and projects received.

I also understand that tutoring/instructional sessions will not exceed 3 hours (daily) and that this program is only available during the school year. *

I understand & agree

Consent to Medical Treatment & Assumption of Risk and Release.

In the event of injury to or illness of the registrant, the undersigned hereby authorizes Sunshine’s Heart, Inc. or representative thereof, to admit the registrant named to a facility for emergency medical treatment as may be deemed necessary to his/her health welfare. The undersigned hereby consents to whatever medical treatment is deemed necessary and releases Sunshine’s Heart, Inc., their board members, staff, volunteers and agents from and against any and all claims and losses, including, but not limited to attorney’s fees and court costs, arising out of the admission to, or treatment administered. *

Yes

No

Media Release - Parental Consent

Please be advised, that when participating in Sunshine's Heart, Inc. Enrichment Program, the registrant may be photographed, videotaped or interviewed at various events. With your consent, the images, video or interview may be used in promotional materials, news releases, social media and other published formats for Sunshine’s Heart, Inc. and its community partners. The images will be the sole property of Sunshine’s Heart, Inc. I understand there is no financial compensation for this agreement and hereby authorize Sunshine’s Heart, Inc. and the members of its staff to take such photographs, recordings and/or live transmission, and likenesses of the registrant. *

Yes

No

I hereby authorize Sunshine's Heart, Inc. and Sunshine's Transportation Services to transport my child on approved fieldtrips and to/from school (if applicable). I understand that Sunshine's Heart, Inc. will use insured transportation companies for transportation. The undersigned hereby acknowledges and agrees that participation in the Academic Enrichment Program and related activities carry with it an inherent risk of physical injury. In consideration of the registrant’s participation in the program, the undersigned, on behalf of the registrant, hereby assumes all such risks of physical injury and does hereby release and forever discharge Sunshine's Heart, its commissioners, staff, employees and agents from any and all liability, claim or loss arising from bodily injuries or damage to personal property resulting from the registrant’s involvement and participation in the program. *

Yes

No

I hereby authorize the registrant to walk to and from the program site. I understand that he/she must enter the building and immediately go to the program area upon arrival. At dismissal, the registrant must exit and leave the grounds immediately. The program reserves the right to revoke permission to walk in cases of inclement weather or activity along the route that may jeopardize the registrants safety. *

Yes

No

Your signature below indicates that you have read, understand and agree to the above items and that the information on this enrollment form is complete and accurate.

Signature (Parent/Guardian) *

Clear