C.O.R.S.E Foundation
Scituate Community Of Resources for Special Education - CORSE
  Home | About Us | Events/News | Sponsors/Donors | Shop CORSE | Proposals | Programs/Registration | Contact Us
header bottom
 

Programs

C.O.R.S.E. Programs

   SPS Academic and Social Skills
   Development Programs

   Program Registration Form

 

 

  Programs & Registration

CORSE Fall 2010 Programs - Registration Form

To register, please complete the form below. There is a $25 late registration fee for any forms received after October 7th.
Unfortunately, we no longer accept out-of-town registrations for these SPS programs, except for students tuitioned into SPS or Scituate students who are enrolled out of district.

Six Week Cycle: October 18– December 3

Participant Name:
Date of Birth
Age:
Grade:
School:
Street Address:
City:
State:
Zip:
Parent's Name:
Home Phone:
Work Phone:
Cell Phone:
E-mail Address:
EMERGENCY CONTACT
IMPORTANT! In case of an emergency situation, the above numbers will be called. Please provide additional Emergency Contact Information below in case the teacher is unable to reach anyone at the above numbers. This person must be available and have access to transportation.
Name:
Relationship:
Phone:
Choose Program  
Student's Primary teacher:
SPED teacher or specialist:
Information regarding Students strengths & weaknesses to assist Instructor:
Medical Conditions
(concerns,allergies,etc.):
Does your child currently receive services via:
Please be assured that all student information will remain confidential.

IEP 

 Yes | No
504 Yes | No
Remediation Yes | No

PAYMENT INFORMATION:

After submitting this data, you will be brought to a page with instructions on sending in a check or paying online with a credit card. If the fee is not received by the registration deadline (February 2, 2010) you may forfeit your spot.

I would like to request financial assistance. By checking this box, Meaghan Baird, the SPS liaison, will contact you. The CORSE Foundation does have financial assistance guidelines developed for fair and equitable access for all students.

Sending a Check | Paying Online w/credit card

Parental Consent, Release from Liability and Indemnity Agreement
(Please read carefully.)

  • I have read the policies and procedures page and fully understand them.

  • I understand and affirm that by registering my child for a CORSE program, I grant permission for SPS, Scituate Recreation and CORSE to use photographs of my child in CORSE, SPS and/or Scituate Recreation publications, materials and websites. If there is a need to avoid photos of your child, you must contact corsefoundation@comcast.net and put your request in writing. Every effort will be made to avoid photos in regards to this request, but it cannot be guaranteed.

I/We, the undersigned father, mother or guardian of the child registered (“my child”), a minor, do herby consent to my child’s participation in voluntary after-school, athletic or recreation programs of the Town/ and /or Public Schools of Scituate (hereinafter “the Town”). I/We also agree to forever RELEASE the Town, a municipal corporation of the Commonwealth of Massachusetts, and/or the Public Schools of Scituate, the School Committee, and all their employees, officers, agents, board members, volunteers, parent/teacher organizations, Scituate CORSE Foundation, Scituate Education Alliance, Friends of Scituate Recreation, Inc. and any and all individuals and organizations assisting or participating in voluntary after-school, athletic or recreation programs of the Town (“the Releasees”) from any and all claims, actions, rights of action, and causes of action, damages, costs, loss of services, expenses, compensation and attorneys’ fees that may have arisen in the past, or may arise in the future directly or indirectly, from known and unknown personal injuries to my child or property damage resulting from my child’s participation in the said Town and/or Public School’s voluntary after-school, athletic or recreation programs which I/we may now or hereafter have as the parent(s) or guardian(s) of said minor child and which said minor child has or hereafter may acquire, either before or after reaching majority.

I/We also promise, to INDEMNIFY, REIMBURSE, DEFEND, and HOLD HARMLESS the Releasees against any and all legal claims and proceedings of any description that may have been asserted in the past, or may be asserted in the future, directly or indirectly, including damages, costs and attorneys’ fees, arising from personal injuries to my child or property damage resulting from my child’s participation in the Town and/or Public Schools of Scituate voluntary after-school, athletic or recreation programs or administration of first aid.

I/We further affirm that I/we have read this Parental Consent, Release from Liability and Indemnity Agreement, and that I/we understand the contents of this Agreement. I/We understand that my child’s participation in these programs is voluntary and that my child and I/we are free to choose not to participate in said programs. By signing this Agreement, I/we affirm that I/we have decided to allow my child to participate in the Town and/or Public Schools’ after-school, athletic or recreation programs with full knowledge that the Releasees will not be liable to anyone for personal injuries and property damage my child or I/we may suffer in voluntary Town and/or Public School after-school, athletic or recreation programs. Permission is granted for any emergency medical treatment needed.

I have read and understand the contents of this agreement and all program polices (this is required for enrollment).

Agreeing Parent or Guardian's Name

Date of Agreement:

By submitting registration I am in agreement with and accepting these terms
 

 

 

 

 

  
 
Scituate C.O.R.S.E. Foundation, P.O. Box 512, North Scituate, MA 02060 | 781-545-7736 | corsefoundation@comcast.net