CFCE Playgroups | CFCE Program

Your Information

First Name*

Last Name*

Email*

Phone

Address

City

State

ZIP

Language Information

Primary Language Spoken at Home*

Other Languages Spoken at Home

Caregiver Information

Will there be a caregiver/grandparent who may bring the child to playgroup?*

Yes

No

Emergency Contact

Emergency Contact Name*

Emergency Contact Phone*

Additional Information

Is there anything else you would like us to know about your child that would help us support your child to have a positive experience?

Is there anything else you would like us to know about the parents/guardians/caregivers who will be bringing the child to playgroup that would help us support a positive experience?

Would you like to be added to our email list to keep informed about our future programming?

Child Information

First Name*

Last Name

Birth Month*

Birth Year*

Allergies, special needs, and/or accommodations (if any)

Media Release*

In order to illustrate and communicate about the work of our educational programs and staff, the Collaborative for Educational Services and staff, or representatives of its programs, plan to photograph or videotape students, staff, families and children, or other participants during CES-CFCE Playgroups and programming.

These photographs, images and/or video and audio taped pieces may appear in CES print and electronic publications, including reports, promotional efforts, video productions, in training or presentations, on the organization's website(s), or in the news media.

We would like permission to use images or video/audio tapes in which you or the child/children for whom you are the parent or guardian appear.

Unless specific arrangements are made with you to do so, we will not identify the subjects by their full name. (See below)

I, , GRANT permission as indicated above to the Collaborative for Educational Services to use, publish or distribute images or video with audio made of me and/or of the child/children named in this registration, either individually or as part of a group; during the programming identified at the top of this form. Images will be used without payment or any other consideration.

PERMISSION IS GRANTED – WITH FULL NAME IDENTIFICATION

PERMISSION IS GRANTED – FOR DE-IDENTIFIED OR FIRST NAME ONLY USE

PERMISSION IS GRANTED – FOR USING IMAGES

PERMISSION IS GRANTED – FOR USING VIDEO WITH AUDIO

I, , do NOT GRANT permission to the Collaborative for Educational Services to use or publish any images or video/audio tapes made of me and/or the child/children named in this registration during the programming identified at the top of this form.

PERMISSION IS NOT GRANTED

The Collaborative for Educational Services will follow the instructions you have provided. These permissions are valid for the school year (July-June) and will be renewed on an annual basis. Permission may be revoked at any time with a signed and dated letter clearly revoking the permission. Thank you.