Account Created

Student Information

Account Details

Student Information Form

Please complete this form for each student you wish to register.

Upload Student Image

Help us recognize your student and put a face to their name! *Max File Size: 2MB

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File Uploaded

Student's First Name *

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Student's Last Name *

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Student's Email

Leave blank if your student does not have an email. * Do not enter your own email. This email address will be used for your student to log into their personal 'Student Dashboard'

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Student's Phone

Leave blank if your student does not have a phone * Do not enter your own phone number.

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Student's Date of Birth *

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Student's Gender *

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Student's School Name *

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Student's Grade *

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Ethnicity Information *

How would you describe the ethnicity of the student? Chickenshed NYC require this information for funding and monitoring purposes.

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Health, mobility, behavior and medication *

Please state information regarding the applicants health, mobility, behavior and medication in order to help us meet their needs more fully whilst at Chickenshed NYC. If not relevant please type N/A

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Emergency Contact *

If we cannot reach the parents or caregivers, who shoud we contact in case of emergency? Please provide the name, relationship, and telephone number.

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Add Additional Parent or Caregiver?

Additional Parent's or Caregiver's Name

Optional

Additional Parent's or Caregiver's Email

Optional

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Additional Parent's or Caregiver's Phone

Optional

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Dismissal Release *

If you wish to have your child dismissed to any adult other than a named parent/caregiver, please provide the name(s) here. NOTE: A photo ID may be required at dismissal.

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Are any other members of the family involved with Chickenshed?

If Yes, Please share some details.

Photographic Release

Yes

At Chickenshed NYC we film and photograph our work for the purposes of documenting, reporting, fundraising and promotions. Imagery and voice recordings captured may be used online and in print including on, but not limited to: Chickenshed's website; social media and YouTube channels; reports to funders (print and email); fundraising materials; newspaper and magazine articles; profiles on third-party websites and publications; marketing brochures and posters. Do you give permission for Chickenshed to record and share images or audio recordings of your student for purposes listed above?

Independent Travel?

If you wish your child to be dismissed by Chickenshed NYC to travel independently.

Send Student Text Notifications?

Yes

Send important reminders, updates and alerts directly to this student's phone. *Unsubscribe anytime.

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Thank you! Your submission has been received!

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Student Added To Your Account!

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Student Name

email@gmail.com

440-364-7379

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Your Student Profiles:

Student Name

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