2019 Workshop Registration Form
Please complete the form below. Fields with an asterisk (*) are required
* Choose a Session:
Confirm your session
Session 1 (Weekdays, June 17 - 28, 2019)
Session 2 (Weekdays, July 8 - 19, 2019)
* Date of Birth:
For the upcoming 2019-20 school year * School: * Grade:
* What type of computer does your child use at home?
No access to computer at home
Please describe any previous experience your child has with the Alice program or other programming languages (previous experience is not necessary for the workshop):
This information is collected so we may communicate with you about the workshop for which you have registered, and as a way to contact you in case of an emergency while your child is attending the workshop. Please be as complete and accurate as possible, and provide information for the parent(s) or guardian(s) who will be transporting the child to and from the workshop. We will not share your contact information with anyone; nor will it be used for any other purpose than the ones stated above.
* E-mail 1:
* Home phone:
Work phone 1:
Work phone 2:
Cell phone 1:
Cell phone 2:
Emergency Contact (other than parents)
All participants must be signed in and out of the workshop each day by a responsible adult. Please list here all people who are allowed to sign your child in or out of the workshop. This includes guardians, parents or step-parents not listed above, grandparents, siblings, neighbors or carpool drivers. A photo ID will be required. If no other people are allowed to sign your child in or out, please write NONE in the space below.
* I give my permission for the following people to sign my child in and out of the workshop:*
Late Pickup Policy
The workshop will begin each morning at 8:30. Participants should be signed in between 8:15 and 8:30 AM. Participants will not be allowed into the classroom before 8:15 AM. The workshop will end each day at 12:00 PM. Participants should be signed out between 12:00 and 12:15 PM. Parents who arrive later than 12:15 will be charged a late fee of $5 per each 5 minutes they are late.
* I have read the Late Pickup Policy and agree to its terms and conditions.
Allergies, medications*, or other medical conditions we should know about:*Our staff is not permitted to dispense medications. Please plan accordingly.
* Physician’s Phone:
Medical and Liability Release
Although every effort is made to create a safe environment, I realize there is always a risk of accident. In case of an emergency involving my child that, in the opinion of the program personnel present, requires immediate medical or surgical attention, I hereby grant permission to the Programming4Girls staff or subcontractors, authority to obtain the service of a physician or Emergency Medical Technician for treatment and/or transport of my child to the hospital if it is deemed necessary. I further release Programming4Girls, and Guilford College, and its facilities, their respective trustees, officers, employees, agents and assigns from all liabilities for injuries or damages arising out of personal injury of any kind. I understand that I am responsible for making Programming4Girls aware of any allergies or medical conditions and limitations that my child may have.
* I have read the Medical and Liability Release and agree to its terms and conditions.
Cancellation and Refund Policy
Programming4Girls reserves the right to cancel a session that has less than 5 participants registered by the Friday before the class is scheduled to begin. If a session is canceled, and the participant is unable or unwilling to attend an alternate session, a full refund will be issued within 3 business days after the participant's session was scheduled to begin.Participants who cancel their registration and withdraw from the class prior to 12:00 PM one week before the session is scheduled to begin will be given a refund of $250 from the $300 registration fee. Cancellations after that date will not be given a refund.
* I have read the Cancellation and Refund Policy and agree to its terms and conditions.
By typing your name below, you are electronically signing this form and attesting that you are the parent or guardian of the child being registered for the workshop, and that you have read all the terms and conditions and wish to proceed with the registration.
* Electronic Signature
* Date Signed
For security purposes, please type in the submission code you see in the image below: