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CIBC After School Program(CAP) Application
We at CAP desire to come under the mission of CIBC, the local Church, by providing homework help to young people in our community. We have a tremendous opportunity in Clarkston to use the resources God has given us to be a part of sharing and showing the love of Jesus to our neighbors, families, and friends. We desire to assist 6th -12th graders not only by providing a place where they can come and focus diligently on their homework and everyday life tasks, but by loving, serving, and sharing Christ with them. At CAP, we do openly celebrate the Gospel and believe Jesus is the hope of the world.
Student's Name: *
First and last name
Your answer
Address: *
Your answer
Phone number: *
Your answer
Text: Yes or No *
Your answer
Email: *
Your answer
Date of Birth: Month/ Day/ Year *
Your answer
School Attending: Grade/ Year in School *
Your answer
Do you attend church: How often? : *
Your answer
Allergies : Yes or No If yes, explain: *
Your answer
Emergency Contact: Name and Phone *
Your answer
Medical Information: Primary physician name/ Phone Number *
Your answer
Medical Insurance Provider and ID Number. *
Your answer
THE RELEASE PERMISSION AND POLICY AGREEMENT
Read Before Signing.
THIS RELEASE, PERMISSION AND POLICY AGREEMENT (“Release”) is given by the undersigned parent or legal guardian of

(“My Student”) in favor of CIBC After school program(CAP) its officers, directors, employees, agents, volunteers, affiliated associations, organizers, sponsors, participants and persons supervising or transporting participants (collectively referred to as “CAP”). In consideration of My Child being allowed to attend “CAP” activities included but not limited to, tutoring and mentoring, retreats, outings and trips, including trips out of the State of GA, I hereby agree as follows:

1. PERMISSION. I hereby give permission to “CAP” for My Child to participate in activities, programs and excursions of “CAP”, including without limitation, “CAP” (collectively the “Activities.”), and I further give permission for “CAP” to transport or to arrange for third parties to transport My Child to, from and during the Activities. I understand that the Activities involve a certain degree of risk. I have carefully considered the risk involved and hereby give consent for My Child to participate in the Activities. Further, I agree that “CAP” does not assume any liability for any personal or bodily injury, property damage or death to My Child while participating in the Activities, and I assume all risks and hazards incident to the Activities. I futher state that my child is in proper physical condition to complete all Activities and futher agree that “CAP” is under no obligation to provide physical examination or other evidence of My Child’s fitness to participate in any of the Activities.

2. CONSENT FOR MEDICAL TREATMENT. I hereby give permission to “CAP” and those associated with “CAP” as and when necessary in case of medical need to administer first aid to My Child and/or to arrange for and authorize emergency medical care, including but not limited to ambulance services, x-rays, anesthesia, medical or surgical diagnosis, tests and treatment or procedures and hospital care, that is recommended, prescribed or directed by any physician, surgeon, nurse or EMT personnel (“Medical Care”). I agree to release and authorize the release of any records necessary for insurance purposes or to obtain Medical Care. I herby give permission to any physican, surgeon, nurse or EMT personnel to provide Medical Care for Child that is requested and authorized by “CAP”. The following Medical Care is not authorized unless the undersigned has been contacted and has given specific permission (if no exceptions, state None).

3. RELEASE OF LIABILITY. To the fullest extent permitted by law, I hereby agree for myself, my heirs, assigns, executors, and administrators to waive, release, discharge, indemnify, defend and hold harmless “CAP” from and against any and all claims, demands, causes of action, liabilities, damages, costs and expenses, including attorneys fees, for bodily injury, disease, death or damage to property arising out of or resulting from My Child’s participation in the Activities (the “Release”), provided that nothing set forth herein will require that I indemnify “CAP” for the consequences of his, her or its sole negligence. I agree that my providing the Release is a material inducement “CAP”’ allowing My Child to participate in the Activities and that allowing My Child to participate is good and adequate consideration for the Release.

4. PHOTOGRAPHER RELEASE. By signing this form, I consent to “CAP” photographing My Child and to use any and all such photographs in videos, articles and/or brochures promoting “CAP”, Activities or for other similar purposes.

By signing, I hereby warrant and represent that I am the legal parent or guardian of My Child and that I have read, understand and agree to the terms and conditions set forth above. I agree to release, discharge, indemnify, defend and hold harmless “CAP” from and against any and all claims, demands, causes of action, liabilities, damages, costs and expenses, including attorney’s fees arising out of or resulting from breach of the foregoing warranty and representation.
Student's Name: *
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(Parent or Legal Guardian): Print Name *
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