Afterschool Form
Please fill out this form in order to leave children in Aftercare.
Student Name *
Grade *
2nd Student
Home Address
Parent/Guardian Names *
Primary Phone
Secondary Phone
Emergency Contact: Name, Phone
Persons Authorized to pick up your child: Name/Phone Number/Relationship
Please list any medical issues or concerns
Medical Action Plan on file in School Office
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St. Mark Afterschool Program will not administer medication.
Primary Care Physician/Address/Phone
Hospital Preference
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?
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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.
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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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