After-School Program Registration
This release and registration form must be filled out completely with current information, agreed upon, signed and turned in before the participant will be allowed to attend the program. All outstanding accounts must be paid in full to attend the program. This form is for the health and safety of the participant.
Participant's Name
Your answer
Grade
Teacher
Your answer
Date of Birth
MM
/
DD
/
YYYY
Age
Your answer
Shirt Size
Your answer
Gender
Address
Your answer
Does the participant have a disability that requires assistance?
Identify any behavior concerns and how to handle them
If none, please write N/A
Your answer
Limitations/Restrictions (Activity/Diet)
If none, please write N/A
Your answer
Is participant taking medication?
Name of medication
If none, please write N/A
Your answer
Will medication be taken during program hours?
Any medical conditions we should be aware of?
Allergy? Asthma? Seizures? Diabetes? Other?
Your answer
Any other information that would be helpful to staff?
Your answer
Participant will attend the program regularly on the following days:
**If you choose the reserved rate and do not attend, you will be charged for that day unless we are notified or your child has been sent home sick.
Required
Rates
Fees
Participant may be dismissed for the following activities:
Your answer
Parent/Guardian Name
Your answer
Relationship
Your answer
Address (if different)
Your answer
Mobile
Your answer
Home Phone
Your answer
Work Phone
Your answer
E-Mail
Your answer
Parent/Guardian
Your answer
Relationship
Your answer
Address (if different)
Your answer
Mobile
Your answer
Home Phone
Your answer
Work Phone
Your answer
E-Mail
Your answer
Person to Notify in Emergency
Name, Number, Relationship
Your answer
Person to Notify in Emergency
Name, Number, Relationship
Your answer
Person to Notify in Emergency
Name, Number, Relationship
Your answer
Physician's Name
Your answer
Physician's Phone Number
Your answer
Medical Coverage
Your answer
Group ID #
Your answer
Preferred Hospital
Your answer
The following people are authorized to pick up participant at the site:
Name, Relationship, Phone
Your answer
Releases and Clauses
Do you agree with the above clauses and releases? If not, the participant will not be able to be enrolled into Rec.
If you agree, below please give: signature, relationship to participant, and date
Your answer
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