Parent First Name
*
Parent Last Name
*
Phone
*
Email
*
Address
Street Address
City
State
Postal code
Student Name
*
Student Birthdate
*
Student Gender
School Name
Teacher's Name
Grade
Does the Student have allergies?
*
Yes
No
Emergency Contact
Emergency First Name
Emergency Last Name
Emergency Cell Phone
Emergency Business Phone
Relationship to Student
Emergency Email
Waivers, Disclaimers & Consent
Parent/Guardian Signature (Type Name)*
Date Signed
Media Release
*
I, the parent/guardian of the child named above give permission for such child to participate in the programs and services of The After School Scholar, and consent to any necessary first aid or emergency medical treatment being given or provided for the child, waive any claims against The After School Scholar, the sponsors of said programs, or any of The After School Scholar, employees or volunteers, in respect to any personal injury to such child or to any other person or any loss of or damage to property, arising in any way at, from or in connection with the programs and services of The After School Scholar. I am providing this waiver on behalf of such child and on behalf of my spouse and any other family members or other persons who might be entitled to assert such a claim as well as on my own behalf.*
Liability Waiver
*
I, the parent/guardian of the child named above give permission for such child to participate in the programs and services of The After School Scholar, and consent to any necessary first aid or emergency medical treatment being given or provided for the child, waive any claims against The After School Scholar, the sponsors of said programs, or any of The After School Scholar, employees or volunteers, in respect to any personal injury to such child or to any other person or any loss of or damage to property, arising in any way at, from or in connection with the programs and services of The After School Scholar. I am providing this waiver on behalf of such child and on behalf of my spouse and any other family members or other persons who might be entitled to assert such a claim as well as on my own behalf.*
Submit
