St. Gregory the Great School - Afterschool Daycare (2019-20)
Student Information
Student Last Name *
Your answer
Student First Name *
Your answer
Student Middle Name (Optional)
Your answer
Grade Level (for the 2019-20 School Year) *
Age *
Your answer
Gender *
Date of Birth *
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Student's Primary Residence Address
Street *
Your answer
City *
Your answer
Zip / Postal Code *
Your answer
Parent/Legal Guardian Information
1st Parent/Legal Guardian
Last Name *
Your answer
First Name *
Your answer
Relationship to Student *
Email *
Your answer
Cell Phone # *
Your answer
Home Phone # *
Your answer
Parent/Legal Guardian Information
2nd Parent/Legal Guardian
Last Name
Your answer
First Name
Your answer
Relationship to Student
Email
Your answer
Cell Phone #
Your answer
Home Phone #
Your answer
Student Release Authorization (Minimum 1 contact required)
I understand that my child must be signed out of the program by an authorized adult (18 years or older with picture ID). In addition to the parent/legal guardian(s) listed on the previous page. I authorize the following additional persons to pick up my child from the site including in the case of emergency:
Emergency Contact #1
First and Last Name *
Your answer
Cell Phone # *
Your answer
Home Phone #
Your answer
Emergency Contact #2
First and Last Name
Your answer
Cell Phone #
Your answer
Home Phone #
Your answer
Emergency Contact #3
First and Last Name
Your answer
Cell Phone #
Your answer
Home Phone #
Your answer
Is there any person to whom your child may NOT be legally released? *
First and Last Name
Your answer
Relationship to Student
Other - Please Explain
Your answer
Medical Information
Does your child have any medical conditions, allergies, or other special needs or problems of which we should be aware? *
If so, please explain.
Your answer
Student Information
Is your child enrolled in the Free and Reduced Lunch Program? *
Is your child designated as an English Learner (EL)? *
Ethnicity (Optional)
Mark the ethnicity with which your child most closely identifies. Please check one:
Race (Optional)
Mark one or more boxes to indicate what you consider your child's race to be.
Student Photo / Product Release
*
Information Release Agreement
I understand that, as part of my child's participation in the Moving Mindz program, the school and/or district may share data including, but not limited to demographic, health, and contact information, attendance, report cards, assessments, and test scores with Moving Mindz to enable Moving Mindz to understand student needs, track student progress, and promote quality program. In addition, Moving Mindz will administer surveys and assessments to evaluate student program and program impact.
Medical Treatment Authorization
In the event my child suffers an illness or accident, I authorize Moving Mindz to seek medical help and assistance by contacting 911 emergency services or otherwise securing treatment at a medical facility. I also acknowledge that Moving Mindz does not provide medical coverage for participants.
Participation Agreement
I understand that Moving Mindz’ primary purpose is to provide a safe and positive environment where students receive the support they need to reach their full potential. I understand that in order to ensure the effectiveness of the program, students should consistently participate in program; that priority enrollment is given to students who commit to attend, and who do attend, in this manner; and that failure to meet this attendance expectation could result in disenrollment.I agree to have my child participate in Moving Mindz programs. I have received the Moving Mindz Parent-Student Handbook, and I understand that participation in Moving Mindz programs is a privilege, not a right, and that my child's failure to comply with the program's rules, regulations, and policies may result in disciplinary action, including but not limited to suspension or dismissal from the program. I acknowledge that if I do not receive a Handbook, I may request one from Moving Mindz. I understand that by virtue of participation, I, or my child, may risk bodily injury and or other loss, including damage to property. I knowingly and freely assume all such risk for myself and my child. I also acknowledge that Moving Mindz does not provide medical coverage for participants and I release and hold harmless Moving Mindz, its officers, agents, contractors, subcontractors, and employees with respect to any and all such injury and or loss, except that injury or loss which results from willful misconduct of Moving Mindz, its employees, or agents. I understand that Moving Mindz and its community partners are NOT accountable for incidents involving my child which occur prior to arrival at or after departure from Moving Mindz programs, including when they are under the supervision of, or have been released from the supervision of another program/activity not supervised by Moving Mindz. I understand my child may not attend any Moving Mindz programs until this form has been completed and submitted. I understand that the submission of this form does not guarantee my child placement in the Moving Mindz program.

By typing my name in the space labeled "Signature" below (which shall constitute my signature), I hereby certify that I am the legal guardian or a parent with legal custody of the above named child, and the information on this enrollment application is accurate and complete to the best of my knowledge. My signature below also indicates that I have read and consent to the agreements and authorizations set forth on this Afterschool Daycare Registration Application form (unless otherwise marked) and in the Parent/Student Handbook (unless otherwise marked). I understand that only the undersigned below will be allowed to authorize changes to this form. I also understand that for safety reasons, I am required to submit in writing any changes of permission for my child to be released to unauthorized individuals. In urgent situations at Moving Mindz' discretion, Moving Mindz may allow oral authorization of such changes subject to verification of the identity of the person making the request.

Parent/Legal Guardian Signature
Please type your First and Last Name *
Your answer
Today's Date *
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