ELEMENTARY ENRICHMENT PROGRAM: FALL 2014
OCT. 27 - DEC 19
Registration Deadline: Wednesday, October 15
$75/course; $50/course for siblings
This form must be submitted to the ASAP office at Wilson Middle School. Want to save a stamp or a trip? Register online!
BEN-HEM
☐ Habitat Explorations: Thursday, Grades 2 – 4
☐ Garage Band: Thursday, Grades 3 & 4
☐ Wild About Art: Tuesday, Grades 2 – 4
☐ Super Sports: Wednesday, Grades 2 – 4
LILJA
☐ Art with Fimo: Thursday, Grades 3 & 4
☐ Domino Rally: Tuesday, Grades 2 – 4
MEMORIAL
☐ Eric Carle-Inspired Art: Thursday, Grades K – 4
JOHNSON
☐ Chess for Beginners: Tuesday, Grades 2 – 4
(Children may only attend courses at their school.)
CHILD’S LAST NAME: ______________________________ CHILD’S FIRST NAME: ________________________
Grade: ____________
Classroom Teacher: _______________________________________________________
Parent/Guardian Name[s] and Phone Number[s]: _______________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Parent/Guardian Email Address[es] (all correspondence is via email): _______________________________________
______________________________________________________________________________________________
_________ _____________________________________________________________________________________
Additional Authorized Pick-Up Persons and Phone Number[s] (must be 18 or older and show photo ID):
______________________________________________________________________________________________
_________ _____________________________________________________________________________________
Medications, allergies, or additional pertinent medical information: _________________________________________
______________________________________________________________________________________________
My child requires access to his/her: ☐ Inhaler
☐ EpiPen
Participation Release:
I/We, the undersigned parents/guardians/legal representatives of my/our child, a minor, do hereby consent to his/her participation
in Natick Public Schools’ Elementary Enrichment Program, including walking field trips around the school neighborhood such as
the Wilson Middle School pond for the Habitat Explorations course. As indicated above, and in consideration of his/her being
permitted to so participate and do, I, on behalf of myself/ourselves and my/our heirs, my/our agents and my/our representatives,
and on behalf of my/our child, do forever RELEASE, acquit, discharge, and covenant to hold harmless, the Town of Natick, and
its successors, and its boards, commissions, committees, officers, employees, servants, agents and representatives, of, from and
against any and all claims, demands, actions, causes of action, charges, lawsuits, loss of services, compensation, costs,
including without limitation attorney’s fees, damages and/or liability of any kind, in any way arising out of or resulting from, directly
or indirectly, all known or unknown personal injuries or property damage or death, which I/we may now have or hereafter have as
the parents/guardians/legal representatives of said minor, as well as any and all claims, demands, actions, causes of action,
charges, lawsuits, loss of services, compensation, costs, including without limitation attorney’s fees, damages and/or liability of
any kind, which said minor has or hereafter may acquire, either before or after he/she has reaches his/her the age of majority, in
any way arising out of or resulting from, directly or indirectly, his/her participation in Natick Public Schools’ Elementary Enrichment
Program.
Parent/Guardian Signature: ___________________________________________
22 Rutledge Road, Natick, MA 01760
Email: mcaprenzi@natickps.org
Date: __________
Phone: 508-647-6400 ext. 1214
Fax: 508-647-6678