Avenue A Fall Programs Registration
Hello Families!  

Having one registration form for the season worked out this summer, so in a continued effort to reduce the number of registration forms you are asked to fill out, here are our fall offerings in one spot!

For Fall program descriptions and specific start dates, click https://avenueatc.org/teen-programs/

Unless specific dates are notated on the program description page, programs run each week that school is in session.

Details related to weather, carpooling, pick-up locations etc. will be sent after registration is complete.

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Email *
First and Last Name (nickname) of youth: *
Date of Birth of participant *
MM
/
DD
/
YYYY
Grade Entering: *
Town of Residence: *
School Name or Homeschool *
Does your child have and medical conditions or allergies? If so, please contact Kim Bylancik, Avenue A Coordinator at 603-831-9958.
 *
Parent/Guardian #1 Name *
Parent/Guardian #1 Phone Number *
Parent/Guardian #1 email address: *
Parent/Guardian #2 or Other Emergency Contact Name *
Parent/Guardian#2 or Other Emergency Contact Phone # *
For participants entering grades 5-8:  If someone other than you may be picking up your child, please record their name(s) and phone numbers below:
Check each program that your youth would like to sign up for. Our Write Out!, Halloween Party, Piesgiving, & Open Hours programs are not listed here because they do not require registration.
Please note the location. Programs with an asterisk * need the transportation waiver signed below. 
 *
Required
TRANSPORTATION PERMISSION (for programs marked with * above).  I give permission for Avenue A staff or volunteers to transport my youth to/from program locations. Any damages/harm resulting arising from the operation of a motor vehicle in relation to the above listed activity, is hereby waived. Please type your signature below to acknowledge your acceptance.
ACKNOWLEDGEMENT OF PERSONAL LIABILITY AND WAIVER -- My child has permission to participate in the above checked programs of Avenue A under the supervision of Avenue A Staff and volunteers during the above mentioned dates (excepting for weather cancellations).   I understand that this program may expose my child to some risks and I assume any such risk that may arise there from.  I accept full responsibility for all medical expenses for any injuries that might occur to my child by reason of their participation.  By signing this form, I release The Grapevine and The Avenue A Teen Center, it's employees and volunteers ("released parties") from and against any and all claims, demands, actions, complaints, suits or other forms of liability that any of them may sustain.  I also agree to indemnify and hold harmless the released parties from the released claims, including any and all related costs, attorney fees, liabilities, settlements, and/or judgements.  I confirm that I have carefully read this consent and release, and I agree to its terms knowingly and voluntarily.  I also confirm that I am the parent or legal guardian of the child.  This consent and release has been read and is understood by me.  Please type your signature below.  
 *
EMERGENCY MEDICAL TREATMENT AUTHORIZATION. I hereby give permission for Avenue A volunteers and staff to provide simple first aid treatments to my child when necessary, and in the event of a more serious illness or injury, I give permission for my child to be transported to a hospital or other emergency medical facility to receive emergency medical treatment. I also authorize ambulance/rescue squad attendants to administer such treatment as is medically necessary, and I authorize licensed health practitioners working in the hospital or emergency medical facility to examine and provide emergency medical treatment to my child if warranted. I understand that I will be contacted by Avenue A/The Grapevine personnel as soon as possible regarding any emergency involving my child. (Please type your signature below)
 *
PHOTOGRAPH RELEASE (OPTIONAL): I give Avenue A/The Grapevine permission to use photos of my child taken during the programs, in press releases, on our websites, and other outreach materials. (Please type your signature below.)
Our programs are offered at no cost to all participants, but if you are able, we could use your support!  Please check below if you can help out in any of the following ways, and we will be in touch to coordinate details!
A copy of your responses will be emailed to the address you provided.
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