Emergency Contact Form
for Chesterbrook PTA Before and After School Enrichment Activities. You can complete one form for each child.
Activity (check all that apply for EACH child)
Required
Student's name
Your answer
Grade
Your answer
Homeroom teacher
Your answer
Parent or Guardian Information
Name (first last)
Your answer
Primary email address
Your answer
Primary Phone number
Please list the phone number we will most likely to be able to reach you during the activity
Your answer
Persons authorized to pick up child other than parent
Name (first last)
Your answer
Primary Phone number
Please list the phone number we will most likely to be able to reach the individual during the activity
Your answer
Persons NOT authorized to pick up child
Name (first last)
Your answer
TWO Emergency Contacts
Name (first last)
Your answer
Primary Phone number
Please list the phone number we will most likely to be able to reach the individual during the activity
Your answer
Name (first last)
Your answer
Primary Phone number
Please list the phone number we will most likely to be able to reach the individual during the activity
Your answer
Student Health Information
Name and phone number of primary physician
Your answer
Health Insurance Plan
Your answer
Health Insurance phone number
Your answer
Health Insurance policy number
Your answer
Please list any allergies, physical limitations or additional medical information if applicable
Your answer
Waiver and consent
I am the parent or legal guardian of the child registering in the before or after school activity designated above. I hereby agree to follow all registration requirements and have read and agree to the After School Pick-up/Drop-off Policy document. I understand that there are certain risks of injury in this before or after school activity and I willing to assume these risks on behalf of my child. I hereby certify that my child is fully capable of participating in this activity. I agree, in taking advantage of this before or after school activity, to release and hold harmless the Chesterbrook Elementary School PTA, including its officers, agents, members, and volunteers; Chesterbrook Elementary School, including its officers, agents, and employees; and any person or persons providing the before or after school activity from any and all claims, demands, suits, costs (including attorneys’ fees and litigation costs) and charges, in connection with or arising out the activity, including but not limited to bodily harm or injury to my child and/or negligence, action, or inaction of the released parties above. In the event of injury, accident, and/or illness of my child, I hereby authorize my child to be transported to an emergency medical facility and authorize the provision of any and all medical treatment which may be deemed advisable. I also hereby assume financial responsibility for any such transport, treatment and/or related expenses. I have read this release and further agree that no oral representations, statements, or inducement apart from the foregoing waiver and consent have been made.
I agree to the waiver and consent
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