Afterschool Form
Please fill out this form in order to leave children in Aftercare.
Student Name *
Your answer
Grade *
Your answer
2nd Student
Your answer
Grade
Your answer
Home Address
Your answer
Parent/Guardian Names *
Your answer
Primary Phone
Your answer
Secondary Phone
Your answer
Emergency Contact: Name, Phone
Your answer
Persons Authorized to pick up your child: Name/Phone Number/Relationship
Your answer
Please list any medical issues or concerns
Your answer
Medical Action Plan on file in School Office
St. Mark Afterschool Program will not administer medication.
Primary Care Physician/Address/Phone
Your answer
Hospital Preference
Your answer
In the unlikely event that your child requires medical treatment during the After School Program hours, would you authorize program staff to seek medical treatment?
St. Mark After School Program is not responsible for medical expenses. Parents will be responsible for any medical expenses should a child incur injury during the Program hours of operation. Untitled Title
St. Mark After School Program to may take pictures/video of my child. I understand that images of my child will only be used in conjunction with or for the After School Program.
By filling out this form, you agree that the information given is accurate and representative of your wishes.
Please fill in today's date. *
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