Little Blue After School Club Registration Form 2016-17
Registration & Information Form:
Dear Parent/Guardian; The AfterSchool Club’s mission is to “Provide an encouraging learning environment that enhances the lives of youth.” This program is under the direction and supervision of Edith Bowen Laboratory School and Utah State University, with the help of AMERICORPS, volunteers, and scholarship interns. We are looking forward to a very fun filled year. Please fill out a form for each child. If you have any questions or concerns, please contact Analisa Smith, AfterSchool Club Director at analisa.smith@usu.edu or 797-3068. Before your child(ren) will be allowed to attend AfterSchool Club, this registration form must competed with appropriate payment.
Child's First Name
Your answer
Child's Last Name
Your answer
Birth Date
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Age
Your answer
Grade
Parent/Guardian Name
Your answer
Preferred Phone Number
Your answer
Home Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Preferred Email
Your answer
Emergency Contact
Your answer
Emergency Contact Phone #
Your answer
2nd Emergency Contact
Your answer
2nd Emergency Contact Phone #
Your answer
My child has permission to:
Required
I certify that my child's immunizations are current:
Other Information: (Allergies, food sensitivities, medication, medical conditions disabilities, behavioral problems, special instructions, etc.)
Your answer
*I hereby give my permission for my child to participate in the Little Blue After School Club. As a parent/guardian, I have discussed the program with the participant. I recognize that there is an element of risk associated with this program, and I acknowledge my acceptance of that risk by participation. I agree to hold harmless from any claim, Edith Bowen Laboratory School, Utah State University, and its associates.
In the event of an emergency, I give my permission for emergency medical treatment to be administered to my child.
I acknowledge that accessibility or use of tobacco, alcohol, illegal substances or sexually explicit materials are prohibited by any person anywhere on the premises during the hours of operation when children are in care.
As a parent/guardian, I am responsible for providing transportation home for my child(ren) promptly at 5:25 pm.
I hereby consent to allow my child’s picture and/or likeness to appear in any official documentary, promotional, exclusive television, radio or film coverage of the Little Blue AfterSchool Club Program in any manner without compensation.
Parent/Guardian Signature:
Your answer
Date:
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***Fee Payment Options (please check): Fee is based on $4.00 per day, with multiple sibling discounts available. *Contact the Director for possible scholarship eligibility. Weekly fee $20 for 1 child; $35 for 2 children per family; $45 for 3 children per family
Required
One time 5$ Registration fee
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