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Name of Location (i.e. Houston, TX, Atlanta, GA,Washington, DC)*

Student Name *

Gender*

Female
Male

Grade Level*

Address*

City*

Zip*

Primary Phone*

Seconrdary Phone

E-mail Address*

Emergency Contact*

Emergency Contact #*

Emergency Contact

Emergency Contact #

Session Selection*

Weekday Sessions (Sept 19 - Dec 5 After School Mon - Thurs 4 - 6 PM)
Weekend Sessions Saturday Sept 24, Oct 1, 8, 22 & 29, Nov 4, 12, 19, Dec 2 & 9

Media Release Agreement

This release form constitute the understanding between Irving and Associates Character Educational Services, Inc. and the participant with respect to the reproduction of the “Read to Excel.”

“Reproduction” means any mechanical rendition or recording of the “Read to Excel Program.” The word “reproduction” includes but is not limited to reproduction by photograph, audiotape, or videotape.
The participant agrees that Irving and Associates Character Educational Services, Inc. shall have the full and exclusive right to reproduce the “Read for Life Program and further grants to Irving and Associates Character Educational Services, Inc. the right to use his/her likeness in any reproduction of the “Read for Life Program.”
The participant agrees that Irving and Associates Character Educational Services, Inc. can use reproduction for advertisement and educational purposes.
Any modification of this agreement shall be in writing and signed by both parties.

I agree*

YES
NO

BEHAVIOR AGREEMENT

Irving and Associates Read to Excel Irving and Associates professionals want to provide positive and enjoyable experiences for all participants. Along with your efforts to help us create that environment listed are a few simple but effective rules. Please check the following if you agree.

I will*

listen, obey and follow the directions of the teacher.

I will*

not hit or fight other people.

I will*

use appropriate language at all times.

Parent Name*

Student Name*

Date*

I understand*

not following these rules can result in dismissal from the program without a refund.

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