Adena PTO After School Program Registration

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E-mail Address: *

Parent's Name: *

Name of Parent or Guardian who is registering the child.

Phone: *

Enter the BEST Phone Number to reach you for the hours of 3:00-6:00pm.

STUDENT INFORMATION

Student's First Name: *

Student's Last Name: *

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.)

Advanced Robotics for Gr. 4-6 on Fridays (Make check payable to Opportunities for Kids for $99)

Arts Spark for Gr. 3-6 on Wednesdays (Make check payable to The Pottery Place for $100)

Chess Scholars for Gr. 3-6 on Mondays (Make check payable to Afterschool Enrichment Solutions for $96)

Delicious Cookies for Gr. 3-6 on Wednesdays (Make check payable to Delicious Designs Cookies for $80)

Let's Build It for Gr. 3-6 on Thursdays (Make check payable to Afterschool Enrichment Solutions for $96)

GO Cars Go for Gr. 3-4 on Fridays (Make check payable to Cathy Cepress for $99)

Kids Home Alone for Gr. 4-6 on Thursdays (Make check Payable to Enriching Kidz $77)

Midwest Cheer for Gr. 3-6 on Thursdays (Make check payable to Midwest Cheer for $85)

Pottery Wheel 101 for Gr. 3-6 on Tuesdays (Make check payable to Enriching Kidz for $83)

Speed and Agility for Gr. 3-6 on Mondays (Make check payable to Explosion Fitness for $90)

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.

No alternate class selected.

Chess Scholars for Gr. 3-6 on Mondays

Delicious Cookies for Gr. 3-6 on Wednesdays

Speed and Agility for Gr. 3-6 on Mondays

Advanced Robotics for Gr. 4-6 on Tuesdays

Arts Spark for Gr. 3-6 on Wednesday

Let's Build It for Gr. 3-6 on Thursdays

GO Cars Go for Gr. 3-4 on Fridays

Kids Home Alone for Gr. 4-6 on Thursdays

Pottery Wheel 101 for Gr. 3-6 on Tuesdays

Midwest Cheer for Gr. 3-6 on Thursdays

RELEASE INFORMATION:

Release Option: *

PICK UP -- My spouse or I or one of the following adults listed below will PICK UP my child at the conclusion of class.

WALK HOME -- I grant permission for my child to WALK HOME alone following their After School Program.

LATCHKEY -- My child is CURRENTLY enrolled in the LATCHKEY program & should be released to the LATCHKEY supervisor following their After School Program.

Spouse's Name:

Spouse's Phone Number:

Adult #1:

Enter name of other Adult who is permitted to pick up your child in addition to your spouse.

Adult #1 Phone:

Phone number of other Adult who is permitted to pick up your child in addition to your spouse.

Adult #2:

Enter name of second other Adult permitted to pick up your child.

Adult #2 Phone:

Phone number of second other Adult permitted to pick up your child:

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:

Insurance Company:

Dentist:

Dentist's Phone Number:

Doctor:

Doctor's Phone Number:

Preferred Hospital:

Medical Treatment: *

In case of an emergency, do you CONSENT or DENY medical treatment and transportation for your child?

CONSENT GRANTED -- In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above named doctor, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentist, concur in the necessity for such surgery, are obtained prior to the performance of such surgery.

CONSENT DENIED -- I do NOT give consent for medical treatment. I wish the Adena PTO or school authorities, or the class instructors to take no action or to:

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.

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

I accept the Policies of the Adena PTO After School Program.

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.

I grant permission for my child to remain after school for their after school program.

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. *

Electronic Signature Confirmation

Required

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