Registration Form
Afterschool Program Registration Form
Email address *
CHILD'S NAME (First & Last) *
Your answer
CHILD'S BIRTHDATE
MM
/
DD
/
YYYY
GENDER
CHILD'S AGE *
ADDRESS *
Your answer
GRADE LEVEL (FALL 2019) *
Parent 1 Name *
Your answer
Parent 1 Address *
Your answer
Parent 1 Phone Number *
Your answer
Parent 2 Name
Your answer
Parent 2 Address
Your answer
Parent 2 Phone Number
Your answer
Emergency Contact & Number *
Your answer
Emergency Contact Relation to Child
Your answer
Please list any allergies child has (Include food allergies) *
Your answer
Please list any medications the child is currently taking. *
Your answer
Please list any special instructions for your child. *
Your answer
I understand that Building Readers First will be open for the afterschool program from 3PM to 6PM. *
Required
I understand that my child/children shall be picked up no later than 6:15PM or I will be charged an additional fee of $25. *
I understand that if my child exhibits poor behavior on a continual basis that he/she will be removed from the afterschool program and payment will not be refunded. *
In case of emergency and Building Readers First cannot reach me by phone. I give consent for my child to be taken to the closest hospital. I give consent by typing my name below. *
Your answer
I/we consent to the use of any video images, photographs, audio recordings or any visual or audio reproduction that may be taken of the subject of this release during the activity/event to be used, distributed or shown as Building Readers First deems appropriate. *
As parent/legal guardian of (child listed above) I give my permission for the subject of this release to be involved in the Afterschool Program. I acknowledge that my child’s participation in the program is voluntary and may require involvement in events that require physical exertion. I acknowledge that his/her participation presents risks that my child may suffer property damage, bodily injury, or death. I/we have reviewed the rules of the activity and agree that the subject of this release will abide by them. I/we understand all reasonable safety precautions will be taken at all times by Building Readers First and its agents during the events and activities. I/we understand the possibilities of unforeseen hazards and know the inherent possibility of risk. I/we agree to hold harmless Building Readers First, its leaders, employees and volunteer staff for damages losses, diseases or injuries incurred by the subject of this release. The undersigned has read and voluntarily signed this release and waiver of liability and indemnity agreement, and further agrees that no oral representation, statements or inducement apart from the foregoing written agreement have been made. Sign your name below. *
Your answer
I'm excited to see all that my child will learn! *
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