Sponsored by the Burrillville  Parks and Recreaction Department

Please make check payable to Learn Well Holistic Education (or LWHE.)

Please print, complete and mail this registration form to:
Jennifer Bergin
155 Steere Street
Harrisville, RI  02830.

Name:    
Address:    
Home Phone:    
Emergency Name/Phone:    
Email Address:    
Class Name:   Class Name: (Check the appropriate box)
Math Moves - Picture This - Memory Power
Allergies or Medical Alert Information  

 

 

 

Waver

I/we, the undersigned for ourselves, our heirs, executors, and administrators, waive, release, and hold harmless the Town of Burrillville and/or Jennifer Bergin, its staff, officers, agents, employees, representatives, successors, and assign of and from all rights/claims for damages, loss to person or property, which may be sustained or occur before, during or after participation in the Foundations Program Classes or anywhere on the demise premises, including the parking lot, which are caused by willful, wrongful act, negligence, or default of the lessee, its agents and servants.

I give Learn Well staff and volunteers permission to release my child(ren) to the following individuals:


______________________________________________________ Full Name
  ___________________________
Relationship to Child
______________________________________________________ Full Name
  ___________________________
Relationship to Child
______________________________________________________ Full Name
  ___________________________
Relationship to Child
     
______________________________________________________ Signature of Parent or Guardian
   ___________________________
Date
     
______________________________________________________ Witness
   ___________________________
Date