DMS Extracurricular Activity Registration
Email address *
Program Option (select one) *
Primary Parent/Guardian's Full Name *
Your answer
Primary Parent/Guardian's Phone Number *
Your answer
Secondary Parent/Guardian's Full Name
Your answer
Secondary Parent/Guardian's Phone Number
Your answer
Student's Full Name *
Your answer
Student's Current Grade Level *
Fees
Please see the website for the current program fees. Payments for most After School Activities qualify as an AZ tax credit. You will be sent a tax credit receipt for your records.

Fees may be paid online at http://desertmarigold.org/programoptions/fees/payments/ or in person at the school office.

Fees must be paid in full prior to the start of the program in order for the student to be secured a space in the activity and placed on the roster.

If financial hardships arise, please contact the office for scholarship assistance.

I agree to pay the fees *
Medical Information
Emergency Contacts *
List names, relationships and phone numbers of two people who could be called if Parent/Guardian listed above cannot be reached.
Your answer
Physician's Name *
Your answer
Physician's Phone Number *
Your answer
Health Insurance Information *
List Name and Group Number
Your answer
Pre-Existing Medical Conditions
List any conditions
Your answer
Medications
List any medications currently taking
Your answer
Allergies
List any food or medical allergies
Your answer
Medications that may be administered to my student (check all that apply) *
Required
Please note any additional comments or conditions that the coaches should be aware of (optional).
Your answer
DMS After School Activity Consent
1) I hereby give my consent for the student named in this form to participate in the Desert Marigold School athletic activity selected in this form, including travel to and forth from said activities, and in other activities that are part of the expanded DMS program. It is my clear understanding that participation in athletic or other activities creates a risk normally associated with such activities, including the potential for catastrophic injury or even death. I indemnify and agree not to hold the School or anyone acting on its behalf responsible for any injury or damage occurring to the above named student, others or property in the course of these extra curricular school program activities. This release shall be binding upon all heirs, estate, executors, administrators, assignees, and for all members of the family.
2) I hereby give permission for DMS’s trained extra curricular staff to administer appropriate medical attention including, but not limited to, first aid treatment and other services, and I authorize the School to obtain a physician of its own choice for any emergency medical care that may become reasonably necessary for my child in the course of athletic activities. In the event of an emergency as determined by the School, I understand that every effort will be made to contact me through the contact information provided, However, I authorize medical help to be sought as quickly as possible. If my contact information changes at any time, I will notify the School immediately.
3) I hereby give permission to DMS to use my child’s image, whether by video, photograph, or otherwise, name/identity and voice in school publications, the school’s web site, chronicles of school activities or events and/or other school publicity including media interviews.
4) I understand that for extracurricular athletic activities, proof of health insurance is required. I certify that insurance coverage is in effect by the insurance card I have provided. I understand I am responsible for any costs not covered by insurance.

By this authorization, I indemnify, release and hold DMS harmless for any and all liability from injuries or damage to property resulting from my child’s participation, for and all liability arising from providing care and treatment to my child, and grant my permission regarding use of the above information. I have read the entire document and agree to be bound by all of its provisions. I further acknowledge that I have read and agree to abide by, support and uphold the rules and regulations of DMS as relates to extracurricular athletic activities.

I have read and understand the After School Activity Consent Form. *
Parent/Guardian Electronic Signature
Your answer
A copy of your responses will be emailed to the address you provided.
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