REGISTRATION

Registration Date:

Mom’s Name:

Mom’s Mobile:

Campus:

Dad’s Name:

Dad’s Mobile:

Student Cartoon $20:

EHA Book Bag $25:

EHA Flashlight $3:

CD Cycle 5 $20:

America CD $15:

Link it! Challenge Cards Printed $35:

Link it! Challenge Cards PDF $15:

T-shirt (XS, S, M, L, XL) $6:

Subtotal:

Sales Tax (VA 6%)

Total:

Emergency Contact: EC Phone:

Email:

Home Address:

Allergies/Special Considerations :

Registration $395/child: .Please pay $175 of the $395 tuition to your Campus Leader.

Please pay $220 of the $395 tuition plus appropriate sales tax to Eden Hope Academy

Please make check payable to: Eden Hope Academy1001 Bowen Court, Great Falls, Virginia 22068

Eden Hope AcademyDedicated to creating Biblically-minded thinkers.

Student’s Name Date of Birth

Eden Hope Academy Releases:

I hereby affirm that my child shall be participating in Eden Hope Academy (EHA). I understand and agree thatneither EHA, the facility or church in which we meet, nor their representatives, instructors or agents may be heldliable in any way for any occurrence in connection with my child(ren)’s participating in any activity associated withor in any way connected to EHA or the facility or church in which we meet which may result in injury, harm orother damages to me or my family. As a part of the consideration for being allowed to enroll and participate inEHA or the facility or church in which we meet and any and all activities associated with or in any way related toEHA or the facility or church in which we meet, I hereby personally assume all risks in connection with mychild(ren)’s participation. I further release EHA or the facility or church in which we meet, its instructors, agentsand representatives for any injury or damage which may befall my child(ren) while my child(ren) is enrolled in orparticipating in EHA and any and all activities associated with or in any way related to EHA. I further agree tosave and hold harmless EHA or the facility or church in which we meet, its instructors, agents and representativesfrom any claim by me or my family, estate, heirs or assigns arising out of my child(ren)’s enrollment and participationin EHA or the facility or church in which we meet and any and all activities associated with or in any way relatedto EHA or the facility or church in which we meet.

I also authorize EHA or the facility or church in which we meet, their instructors or representatives to render orobtain emergency medical care or treatment should such be necessary while participating in EHA or any and allactivities associated with or in any way related to EHA or the facility or church in which we meet.

I further state that I am of lawful age and legally competent to sign this affirmation and release; that I understandthe terms herein are contractual and not a mere recital; and that I signed this document of my own free act andvolition. I further state and acknowledge that I have fully informed myself of the contents of this affirmation andrelease by reading it before I have signed it. I have executed this affirmation and release on the ___ dayof ________ 20____.

Signature __________________________________________________________

Photograph Release:

I hereby authorize and give full consent to Eden Hope academy to publish and copyright all photographs in whichmy child appears while enrolled as a student in Eden Hope Academy activities. Children will not be identified byname in photo captions. I agree that Eden Hope Academy l may use, in whole or in part, photographs, videos,written extractions, and voice recordings of my child for the purpose of illustrations, publications, and websites.Additionally, I agree that use of a photograph or photograph(s) does not constitute in any manner a waiver ofEden Hope Academy policies, or rules, nor does the continued use constitute an agreement to continue the child’senrollment in the program. I hereby approve the foregoing and consent to the use of photographs subject to theterms mentioned above. I affirm that I have the legal right to issue such consent.

I authorize this release.

Signature Printed Name Date