Enrollment Form

Please complete this form for each child you seek to enroll. If you have any questions or you experience ANY difficulties completing this form, please contact us at (617) 340-9907 or welcome@theinnovationinstitute.org.

Child's First Name *

Child's Last Name *

Child's Date of Birth *

Date

Child's Age *

Entering Grade (Sept. 2016) *

Gender *

M F

Day School Name or Indicate Home Schooled *

City *

Please Enter Term(s) Sought for Enrollment. (Select all that apply.)

Select Course: Fall-Spring Academic Year

Please select the academic year course(s) in which you seek enrollment.

Select Course: Summer Session Courses

Please select the summer course in which you seek enrollment.

If "Other," Please Provide Grade and Course Title

Class Day

If summer session, please select "one week." If registering for multiple summer sessions, please select "multiple weeks."

Class Start Time (Fall, Winter, Spring Terms)

Summer Session

9 AM - 12 PM Afternoon programming @ $20/hour (rate maximum per child, per hour)

Parent/Guardian 1 First Name *

Parent/Guardian 1 Last Name *

Home Address *

Apt.

City *

State *

Postal/Zip Code *

Primary Phone Number [1] *

Alternate Phone Number [1]

Text Messaging for Primary Phone Number? [1] *

Text Messaging for Alternate Phone Number? [1]

Primary E-mail Address [1] *

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Home Address 2, if Different from Above.

Apt. [2]

City [2]

State[2]

Zip Code[2]

Parent/Guardian 2 Primary Telephone Number

Parent/Guardian 2 Alternate Phone Number

Text Messaging for Primary Phone Number? [2]

Text Messaging for Alternate Phone Number? [2]

Parent/Guardian 2 E-mail Address

Please tell us how you learned about us. Check all that apply. Thank you. *

magazine advertisement web search online listservs (e.g., online home school network, online families for City of Belmont, etc.) personal referral (word of mouth) saw an advertisement posted in an office, playground, physician's office, etc. received a postcard at home address PTO communication

We seek to make a student's transition into our program as seamless as possible. The following questions are optional. The information you provide will be shared with relevant staff members only. Your comments will be used solely for internal purposes. Thank you.

Is this your child's first after-school academic enrichment experience?

yes no

How would you characterize the decision to enroll at The Innovation Institute?

strongly encouraged by parent joint decision between parent(s) and child child-initiated decision

How can we make your child feel comfortable?

Is your child more likely to gravitate towards peers or adults?

What role does your child take in social situations with peers?

How does your child deal with transitions (time constraints, unexpected changes, disruptions to schedule, separation from you)? Particularly for our youngest children, please take some time to comment on how we can help facilitate your departure after drop-off. What sorts of things make your child nervous/frightened/anxious?

How does your child deal with frustration?

Have there been any events or changes in your child's life recently that might impact his/her mood or behavior? If so, please explain. What strategies work at home or school to manage challenging behavior?

Does your child have any known or suspected learning challenges? If so, please describe in detail. Thank you.

Please share anything we haven’t asked about that you think it would be helpful for us to know. Thank you.

Pick Up and Drop Off Protocol For the safety and security our students, staff, families and professional and residential neighbors, we ask that you please abide by the following pick up and drop off authorization form and protocols. Thank you.

1. Students accompanied by parents, legal guardians or other specifically authorized individuals must be dropped off and picked up within Suite 300 , the location of the The Innovation Institute at 288 Walnut Street, Suite 300 , Newtonville, MA 02460. NEVER DROP YOUR CHILD OFF OUTSIDE OF 288 WALNUT ST BUILDING AND CONSIDER YOUR CHILD WITHIN THE CARE OF THE INNOVATION INSTITUTE. 2. The Innovation Institute is not/and cannot be responsible for and cannot and/does not count students as present unless they are within Suite 300. 3. The Innovation Institute will not recognize exceptions to drop off and pick up protocols unless authorization forms have been completed in writing in advance by a student's parents or legal guardians. 4. If a student is/will be absent from class, please notify The Innovation Institute via e-mail (welcome@theinnovationinstitute.org) or phone 617 340-9907. Thank you. 5. Please note that while on the premises of 288 Walnut Street, a policy of silence or quiet conversation is required, as other organizations are conducting their work. 6. Under no circumstances, including lateness, should drop-off or pick-up vehicles be parked illegally (i.e., in parking lot spaces behind, next to, or in front of 288 Walnut Street [including The Innovation Institute sign-posted spaced, which are for staff only], double-parked or in any way blocking area traffic potentially or in actuality). Any and all of these activities are cause for dismissal from The Innovation Institute Program without a refund per The Innovation Institute's "Terms of Service" and agreed to during the enrollment process. (http://theinnovationinstitute.org/terms-of-service) 7. Please use two-hour metered and non-metered, on street parking in the neighborhood, abiding by all signs/placards, rules and laws. Please also make use of the Austin Municipal Parking Lot, directly across from Starbucks and Star/Shaws Market for parking. It is one and one-half blocks from The Innovation Institute. 8. No child will be released to any person not previously authorized in writing on The Innovation Institute's "Dismissal Authorized Alternates" form. All authorized persons will be asked to show a valid photo ID. Please do not take offense to this protocol; it is for the safety and security of all students who are accompanied by adults to and from The Innovation Institute. 9. Please make sure that a student does not leave with the authorized person without the explicit knowledge of the dismissal staff on duty.

10. No student will be dismissed unaccompanied or with other adults unless previously authorized on The Innovation Institute's "Unaccompanied Dismissal" or "Dismissal to Other Authorized Adult" forms. Thank you for your cooperation.

If you wish to give your child written authorization to leave with another adult you identify or depart unaccompanied upon dismissal, please complete this section. If not, please answer "yes" to skip this section.

Skip Section *

yes no

Student Dismissal to Authorized Persons Should you wish to authorize someone other than yourself and the other parent/legal guardian named on this form to pick up your child, please provide the alternate person's contact information below. Please note that the dismissal and departure location is from within The Innovation Institute, defined as within suite 300 , at 288 Walnut Street, Newtonville, MA. Thank you.

I do NOT seek to authorize anyone else to pick up my child after class.

True

Alternate Pick-Up Person's First Name

Alternate Pick-Up Person's Last Name

Telephone Number

Alternate Telephone Number

Texting Number

Primary E-mail Address

Release of Liability, Waiver and Indemnification Agreement

Child's Full Name *

First Name Last Name

Parent/Legal Guardian's Full Name *

First Name Last Name

I, identified above by name as parent/legal guardian, the undersigned, hereby authorize The Innovation Institute, its officers, staff, agents, employees and volunteers to dismiss my child, named above, to the undersigned, or an authorized guardian and/or caregiver named above from The Innovation Institute, within suite 300, at 288 Walnut Street, Newtonville, MA 02460. I understand that this DOES NOT include unaccompanied dismissal from the Innovation Institute’s suite 300 premises (e.g., the lobby of 288 Walnut Street, Newtonville, MA 0260 and its environs) to meet any of these authorized individuals.

In consideration for permission for such dismissal, I do hereby, for myself, my heirs and assigns, and on behalf of my child/ward, and for his or her heirs and assigns, release and agree to indemnify and hold harmless The Innovation Institute, it officers, staff, agents, employees and volunteers from any and all liability, loss, claim, demand, action, or cause of action which arises or may arise or be occasioned in any way by such dismissal.

I have read the above information and I understand and agree to its content. I am fully aware of the legal consequences of signing this agreement and do so voluntarily.

Authorizing Parent/Guardian Signature *

Clear

Date

Month Day Year

Unaccompanied Dismissal Authorization

Should you wish to give permission to your child to leave The Innovation Institute, defined as within suite 300 at 288 Walnut Street, Newtonville, MA 02460, upon dismissal, please indicate below.

My child has my permission to arrive and leave unaccompanied by an adult. *

Release of Liability, Waiver and Indemnification Agreement

Parent/Legal Guardian's Full Name

First Name Last Name

Child's Full Name

First Name Last Name

I, (identified above by name as parent/legal guardian), the undersigned, hereby authorize The Institute, its officers, staff, agents, employees and volunteers to dismiss my child/children, (named above), unaccompanied by me, the undersigned, or an authorized guardian and/or caregiver from the Innovation Institute, within suite 300, at 288 Walnut Street, Newtonville, MA 02460. This includes unaccompanied dismissal from the Innovation Institute’s suite 300 premises (e.g., the lobby of 288 Walnut Street, Newtonville, MA 02460 and its environs) to wait for pick up by private of public transportation or for unaccompanied departure for another destination.

In consideration of permission for unaccompanied dismissal, I do hereby, for myself, my heirs and assigns, and on behalf of my child/ward, and for his or her heirs and assigns, release and agree to indemnify and hold harmless The Innovation Institute, it officers, staff, agents, employees and volunteers from any and all liability, loss, claim, demand, action, or cause of action which arises or may arise or be occasioned in any way by such dismissal.

I have read the above information and I understand and agree to its content. I am fully aware of the legal consequences of signing this agreement and do so voluntarily.

Signature of Arrival and Dismissal Authorization by Parent/Legal Guardian

Clear

Date

Month Day Year

We are eager to share with you some of the many wonderful activities in which children are engaging in our classrooms, from building three-dimensional DNA models to allowing a woolly bear caterpillar ("Pyrrharctia Isabella") to crawl on their hands.

To do so, we need your consent to take and share photos and video clips of our class activities and related Innovation Institute events. Typically, we will use these media:

• in our electronic newsletters, blogs, website communications and other online communications mechanisms, etc.

• to communicate with you and/or other parents about the class's work in which your child is enrolled.

• to document and/or create class projects

• for instructor training purposes

• to help others (families and community members at large) understand our programs.

We also anticipate that periodically, we may have more indepth media requests to communicate about The Innovation Institute with the public.

Below we ask that you indicate whether you permit us to use photos/videos for all such purposes. Neither photos nor videos will be sold or reproduced for profit. Thank you in advance for your consideration.

Child's Name *

First Name Last Name

Please select one media release option. *

I give permission to use my child’s comments, photographs/or presence in video clip to be used by The Innovation Institute for its programs, communications, teacher training, including its publicly accessible website, blogs and other online media outlets (e.g., Facebook, Linkedin, etc.). I DO NOT give permission to use my child’s comments, photographs/or presence in video clip to be used by The Innovation Institute for its programs, communications, teacher training, including its publicly accessible website, blogs and other online media outlets (e.g., Facebook, Linkedin, etc).

I certify that all information I have provided is complete and accurate. I agree to notify The Innovation Institute of any changes to the information provided as soon as I become aware of them. *

yes

I have read, understand and agree to The Innovation Institute"s Terms of Service, Cancellation and Refund Policy and Privacy Policy. (These documents are available via the "policies" menu at http://theinnovationinstitute.org/policies/.) *

yes

I have read and understand the media authorization and release to photograph and/or video my child and release The Innovation Institute and its affiliates, employees, directors, agents, and volunteers from any and all claims based on the use of the above described material(s) and convenant not to make or bring any such claim against any such organization and/or persons.)

yes

PDF Downloadable versions of:

Terms of Service
Cancellation and Refund Policy
Privacy Policy

I have read, understand and agree to all of the the Pick-Up and Drop-Off Authorization Protocols as stated on this form. *

yes

I agree to read/review and ensure that my child understands the Innovation Institute's Code of Conduct. *

yes

PDF downloadable version of The Innovation Institute's Code of Conduct (written by our middle school students).

I have read, understand and indicated my decision pertaining to my child and the use of photos and media.

Acknowledgment *

yes

Authorized Parent/Guardian SIgnature *

Clear

Full Name *

First Name Last Name

Today"s Date *

Date

I have downloaded, read and understand the "Student Preparation Sheet." PDF downloadable version.

I will provide a current medical form that proves my child is up to date with all medical immunizations.

Acknowledgment *

yes

Acknowledgment *

Yes

I have paid or am about to pay the $75.00 annual registration fee (by credit card or check), which is nonrefundable. I understand that I only pay the registration fee once per academic year. Alternatively, I understand that school vacations and summer sessions do not require a registration fee. *

yes

I have paid or am about to pay the tuition and materials fees via credit card or check. I understand that the materials fee is nonrefundable should I seek a tuition refund within the terms of service. *

The Innovation Institute 288 Walnut Street, 300 Newtonville, MA 02460 617 340-9907 welcome@theinnovationinstitute.org theinnovationinstitute.org