2012 CHEM Registration Form
Before completing this form please be sure to have read
“Details Regarding Our Commencement Exercises” and the “Registration Information for 2012”
TO REGISTER: Complete the three page form, sign the waiver, and send your completed
Form along with payment according to the instructions on the last page.
Graduate’s Name ________________________________M ___F ___
Father’s Name _______________ Mother’s Name ________________
Address ________________________________________________
City ______________________ State _________ Zip ___________
Parent’s Telephone Number & E-mail ___________________________
Parent’s Facebook Name, IF want to join ________________________
Graduate’s Cell & E-mail ____________________________________
Graduate’s Facebook Name, IF want to join ______________________
Cap & Gown Measurements:
Only show measurements for the items you are personally ordering.
Chest – Measure around the chest/under the arms and record in inches ___________
Take care in measuring the chest size being sure to take the measurement at the fullest portion of the
chest. If a gown has to be reordered because of the wrong size you may be charged a $15 return and
shipping fee, as this is the additional amount the company is charged from the manufacturer.
Height – Record full height in feet and inches wearing flat shoes
___________
Girls, if wearing 3” heels in the ceremony, add 2” to the height measurement.
Cap Size – Place the measuring tape around the head about 1 inch above the ears, pulling tape snug.
If this number is 25 inches or less, check this “one size fits all” line
____________
But, if this number is 25 1/8 inches or more record the measurement in inches ____________
The Cap & Gown Coordinator will contact you with the additional cost for a “fitted” cap.
A fitted cap will not be needed for most graduates
Registration Form – Page 2
Please read and then sign Form below.
Please Note: All students who are 18 and older, as well as at least one custodial parent or the legal
guardian, regardless of whether the student is 18 or not, must sign the Agreement below:
RELEASE AND WAIVER OF LIABILITY;
HOLD HARMLESS AND INDEMNITY AGREEMENT
I/We hereby release CHEM and its officers, agents, representatives, and those acting or
appearing to act on behalf of CHEM from all liability for any and all activities and events that
are sponsored, promoted, or suggested by CHEM, as well as for all actions and decisions made
by CHEM and its officers, agents, representatives, and those acting or appearing to act on
behalf of CHEM regarding CHEM graduation and student-led senior year activities of any and
all kind and waive all rights, claims, liability, and actions of any and all kind, including those
involving civil rights, against CHEM regarding CHEM graduation and student-led senior year
activities of any and all kind.
Additionally, I/We agree to hold harmless and indemnify CHEM and its officer, agents, and
representatives from any and all liability connected with or associated with student-led senior
year activities of any and all kind that I/We engage in.
I/We have read and understand this agreement, and agree with its terms.
DATED: _______________________
_______________________________
STUDENT (Sign, then print name below)
_________________________________________
CUSTODIAL PARENT/GUARDIAN (Print name below)
_______________________________
_________________________________________
Student must sign and print for themselves
Why the Need for A Signed Waiver of Liability ~
Since CHEM’s operating structure is through a simple planning committee with a couple moms coming together each
year to host this event, as a service to the local homeschool community, insurance coverage is obtained through the church in
which the graduation ceremony is held instead of carrying an individual policy. This insurance provides liability coverage only
while graduates, their families, and guests are on the church’s property. For this reason CHEM does not sponsor or host any
off-site activities for our graduates, though we do suggest that graduates and/or their parents hold their own personal events
should they desire to do so. Unfortunately, the last few years has seen a rise in law suits against homeschool groups and
chaperones of school activities so, we are asking that each of our graduating families sign the above “Release and Waiver of
Liability; Hold Harmless and Indemnity Agreement” in the event their graduate participates in any student-led senior year
activities. We believe the liability/injury risk from senior year activities should be no different than any other activity you
would personally plan to hold on your own premises or at a public location where your homeowner’s and automobile policy, as well
as the public facility’s policy would provide coverage in the event an accident or injury should occur (there has been none to
date). We trust you will be in favor of signing the waiver. If not, we ask that you not take part in any of the senior year
activities. Thank you for your understanding!
Registration Form – Page 3
Fill in the Registration Fees that apply to you and submit with payment as detailed below
Registration Fees for Participation in the 2012 CHEM Graduation Ceremony
$148.00
Participation Fee
$ 74.00
Participation Fee –
$ 24.50
Standard Diploma
$ ____________
$ 27.50
Cap & Gown with Tassel
$ ____________
$ 16.50
~ or ~ Cap & Tassel only –
$
~ or ~ Tassel only –
8.00
$ ____148.00___
additional sibling(s)
if have gown
if have gown & cap
Your Total Registration Fees
$ ____________
$ ____________
$ ____________
$ ____________
Payment – Due in full by February 15, 2012
Deposit – $25 minimum payment due now to hold your spot
$ (-
)
(If you worked last year’s graduation no minimum deposit is require to hold your spot
but, return this form ASAP to show your intent to participate. Full payment is still due by 2-15-2012)
Balance –
payment in full due between now and 2/15/2012
$ ____________
(If needed, the balance can be paid in installments; please contact us to make arrangements.)
~ or ~
If paying in full before December 15, 2011
Subtract $10 from the Balance
$ (Balance –
payment in full due between now and 12-15-2011
)
$ ____________
Make Check or Money Order Payable to C.H.E.M.
Bring this form with your payment to:
the Fall Information Meeting
Tuesday, October 25, 2011
at Ward Church, Northville
~ Or ~ Mail this form with your payment to:
Mrs. Angela Morgan
Registration Coordinator
24376 Rougecrest, Southfield, MI 48033
For Additional Information: 313-377-0840 (cell) or morganhouse06@yahoo.com