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Thank you for your interest in enrolling your student in the ABC to PhD Saturday Enrichment Academy, powered by the Southern Nevada Black Educators Initiative (SNBEI) and Nevada Partners. This program is designed to enhance literacy, math, and science skills for Pre-K-2 students in a supportive and engaging environment. Please complete this form to provide the necessary information and to acknowledge our policies and waivers. This program is offered at no cost to the community, but space is limited, and enrollment will be on a first-come, first-served basis. Submission of this form does not guarantee a spot in the program. We look forward to supporting your student’s academic journey and partnering with you to create a pathway from their ABCs to PhDs!
Last Name
First Name
Date of Birth *
Parent/Guardian/ Care-Taker Information
Phone *
Address
Emergency Contact Information *
Phone *
To participate in the program, children must meet the following requirements: 1. Be at least 4 years old by the program start date. 2. Be fully potty trained prior to attendance. Eligibility Confirmation:
Health & Safety Information
If this does not apply to your child, please enter "N/A."
Phone
By signing below, I, the parent/guardian/care-taker of the student listed above, agree to the following: 1. Assumption of Risk: I acknowledge that participation in the ABC to PhD Saturday Academy involves various activities and interactions, which may carry inherent risks, including exposure to illnesses or communicable diseases. I understand that while SNBEI takes reasonable precautions to ensure a safe and healthy environment, it cannot guarantee that my child will not be exposed to illnesses, including those potentially resulting from being unvaccinated. 2. Release of Liability: I release the Southern Nevada Black Educators Initiative (SNBEI), its staff, volunteers, and partners from liability for any injuries, illnesses, or incidents that may occur during the program, except in cases of gross negligence or intentional misconduct. 3. Emergency Medical Consent: In the event of an emergency, I authorize SNBEI staff to take necessary action, including seeking medical treatment for my child, until I can be reached. I understand that I will be responsible for any medical expenses incurred. 4. Acknowledgment of Program Policies: I understand and agree to comply with all program policies, including health and safety guidelines, and will promptly notify SNBEI of any changes to my child’s health status, including exposure to communicable diseases. 5. Personal Belongings: I agree that SNBEI is not responsible for any lost or stolen personal items during the program.
Full Name
Date
By enrolling my child in this program, I understand and agree to: 1. Provide accurate information on this form. 2. Failure to pick up your child at the designated time may result in a $25 fee for every 30 minutes past the scheduled pick-up time and/or removal from the program. 3. Communicate promptly with SNBEI about any changes to my child’s health or availability.
Photo/Video Release *
By enrolling my child in the ABC to PhD Saturday Academy, I acknowledge that photos and videos may be taken during program activities for educational, marketing, and promotional purposes, including but not limited to ClassDojo, social media, websites, and other program-related materials. I understand that these images and recordings may be used to highlight the impact and success of the program and that by signing this enrollment application, I grant permission for my child’s image to be used accordingly.
Full Name
Date

Thank you for completing the application for the ABC to Ph.D. Saturday Enrichment Academy! We appreciate your interest in this transformative program, powered by the Southern Nevada Black Educators Initiative (SNBEI) and Nevada Partners.

Due to high demand, we have reached capacity, and your student has been placed on our waitlist. If space becomes available, we will notify you as soon as possible. We appreciate your patience and commitment to your child’s academic success.