Adena PTO After School Program Registration
E-mail Address: *
Your answer
Parent's Name: *
Name of Parent or Guardian who is registering the child.
Your answer
Phone: *
Enter the BEST Phone Number to reach you for the hours of 3:00-6:00pm.
Your answer
STUDENT INFORMATION
Student's First Name: *
Your answer
Student's Last Name: *
Your answer
Grade/Homeroom Teacher: *
(If your child does not attend Adena Elementary, select "Non-Adena student")
Class: *
You child will be registered for ALL the classes selected. Write a check for EACH class as directed. (Please DO NOT send a check for CLOSED or Waitlisting classes! We will contact you if there is an opening.)
Required
Alternate Class:
If your choice of class above is cancelled or full, we will automatically enroll your child in the alternate class you select here. Please DO NOT send a check for the Alternate class until we notify you and ask you to send a check for the alternate class at that time.
RELEASE INFORMATION:
Release Option: *
Spouse's Name:
Your answer
Spouse's Phone Number:
Your answer
Adult #1:
Enter name of other Adult who is permitted to pick up your child in addition to your spouse.
Your answer
Adult #1 Phone:
Phone number of other Adult who is permitted to pick up your child in addition to your spouse.
Your answer
Adult #2:
Enter name of second other Adult permitted to pick up your child.
Your answer
Adult #2 Phone:
Phone number of second other Adult permitted to pick up your child:
Your answer
EMERGENCY INFORMATION
Please be aware that any medications stored in the nurses office at school are locked and there are no nurses or staff in the main office much beyond 3:30 pm. IF YOUR CHILD HAS A MEDICAL ISSUE THAT POTENTIALLY REQUIRES URGENT ACCESS TO MEDICATIONS, PLEASE MAKE A PLAN WITH YOUR AFTER SCHOOL INSTRUCTOR.
Responsible Party:
Your answer
Insurance Company:
Your answer
Dentist:
Your answer
Dentist's Phone Number:
Your answer
Doctor:
Your answer
Doctor's Phone Number:
Your answer
Preferred Hospital:
Your answer
Medical Treatment: *
In case of an emergency, do you CONSENT or DENY medical treatment and transportation for your child?
Your answer
Other Information:
Facts concerning the child's medical history, including allergies, medications being taken and any physical or learning issues to which a physician or instructor should be alerted may be included here.
Your answer
Release and Acceptance
Policy Acceptance: *
Policies of the Adena PTO After School Program may be found at the link http://www.opportunitiesforkids.com/Policies.html
Required
Permission to remain after school: *
If you check this box, you grant the Adena After School Program and Adena staff to accept your permission electronically for your child to remain after school on they days they have after school programs. This replaces the requirement for parents to send in a signed, paper permission form.
Required
PLEASE TYPE YOUR NAME INTO THE BOX BELOW. BY CHECKING THE "CONFIRM E-SIGNATURE" BOX, YOU ARE VERIFYING THAT YOU ARE THE PARENT AND/OR LEGAL GUARDIAN OF THE ABOVE MENTIONED STUDENT AND AGREE TO THE ABOVE MENTIONED TERMS. *
Your answer
*
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service