Special SMA Application

Student - Member Application

For a parent, guardian or family member (over 18), applying
for themself, children in a family, or an entire family

Your first class registration is not complete until you submit this form

Your 1 year Student - Member Application starts today:

* Indicates required field

Fill in today's date *

If known, please select the teacher's names for classes you or family members will attend:

Primary Applicant

Name of Parent, Guardian or Family Member (18+ years old), applying for one or more family members *

First

Last

Unless you plan to attend classes or events yourself, you do not need to fill in your Gender and Birthday:

Gender *

Birthdate *

Are you applying for family member/s ONLY, or for yourself and family member/s together? *

Other family member/s ONLY Myself and other family members

Family Contact Information

Primary Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Email *

Primary Phone or Cell # *

Family Member Information

Only complete information for your spouse if they plan to attend classes or events

Name of Spouse (if applicable) *

First

Last

Gender *

Birthdate *

Email for spouse *

Phone or Cell # for spouse *

Children who will participate in classes or events

Name of Child 1 if applicable: *

First

Last

Gender *

Age *

Birthdate *

Name of Child 2 if applicable: *

First

Last

Gender *

Age *

Birthdate *

Name of Child 3 if applicable: *

First

Last

Gender *

Age *

Birthdate *

Child 4 if applicable: *

First

Last

Gender *

Age *

Birthdate *

Additional Information About Children or Famiy Members

Do any of your applicants have special needs? *

Yes No

If yes, please explain: *

Is there anything else we should know about your applicants? *

Is there anyone who should not pick up your child or children from Heart Encounters? *

Emergency Contact Information
Your spouse or another emergency contact

Emergency Contact Name *

First

Last

Email *

Phone Number *

Agreement

The primary applicant must read and respond to the following agreement before they or their family members participate in any class or event at Heart Encounters.

These agreements apply to both you and your family members.

Accident, Injury and Liability

I understand and agree that by participating in any class, workshop, activity, event, rehearsal or performance, there is the risk of injury. I voluntarily agree, because of my choice for me and/or my family members to participate in classes, programs, activities or events provided, to assume all risks and responsibility for any such injury or accident which might occur to me or my family members during any of the Heart Encounters classes, programs, activities and events. I also voluntarily agree to waive my rights and the rights of my heirs, to hold Fayette County Board of Education and Heart Encounters, its owners, agents teachers, volunteers, assistants, employees, guest artists, faculty members and/or students, liable for damage, loss, injury or death due to the ordinary negligence which may arise out of or in connection with participation in any classes or activities conducted by Heart Encounters.

Check to Agree *

Agree

Publicity Photos

I give Heart Encounters permission to use photographs of myself or my family, for publicity purposes. If I check Opt-Out, I agree to email Heart Encounters to confirm my decision at: [email protected]

Check to Agree or Opt Out *

Agree Opt Out - No Photos

Dropping a Class

Please let us know if you or your family members need to drop a class. If payment has been made to a teacher at the time the class is dropped, is up to the teacher to decide whether to refund payments already made at the time the class is dropped. All payments for classes go directly to teachers. Payment questions, concerns or issues are to be worked out between you and the teacher. If you have questions before starting a class, please discuss your questions with the teacher.

Check to Agree *

Agree

Notice of Exemption

I acknowledge that I have been informed that Heart Encounters is not a licensed child care facility. I also understand that Heart Encounters is not required to be licensed by the Georgia Department of Early Care and Learning, and Heart Encounters is exempt from state license requirements.

Check to Agree *

Agree

Payment for Classes

Heart Encounters Teachers and Equippers set the fees they charge for their classes/events. They keep all payments they receive. Equippers and Teachers donate to Heart Encounters out of payments they receive. We all function as a community, contributing as we are able so Heart Encounters can continue serving our local community. We expect Teachers and Equippers to take this into account when setting the amount they charge for classes/events. We evaluate Heart Encounters' financial status regularly, to assess our class payment policy and we reserve the right to change and be flexible according to the financial state of Heart Encounters. Donations from students, families and sponsors are always welcome and appreciated.

Check to Agree *

Agree

Class Conduct

Heart Encounters endeavors to maintain a safe and enjoyable family atmosphere. We expect students to respect teachers and school property. Because we often have multiple classes in session at the same time, we ask parents to be sure children do not run in the hallways and that everyone uses quiet voices, so classes are not interrupted. Parents should drop off and pick up children when classes begin and end. We appreciate your help in keeping our school safe and secure.

Check to Agree *

Agree

Agreement to All of the Above

To confirm your answers, please enter your full name: *

Submit