After School Enrichment — West Georgia Star

AFTER SCHOOL Enrichment Program Sign Up

Name of Leaseholder

For LHA Residents Only

First Name

Last Name

Address

Name of Child

First Name

Last Name

Grade of 2016 - 2017 School Year

Name of School

Home Phone

(###)

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Date of Birth

YYYY

Gender

Ethnicity

Parent/Guardian Information

Mother's Name

First Name

Last Name

Mother's Cell Phone

(###)

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Mother's Employer

Father's Name

First Name

Last Name

Father's Cell Phone

(###)

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Father's Employer

Emergency Contact Information

Contact #1

First Name

Last Name

Contact 1 Relationship

Contact 1 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact 1 Cell Phone

(###)

###

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Contact 1 Home Phone

(###)

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Contact 1 Work Phone

(###)

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Contact 2

First Name

Last Name

Contact 2 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact 2 Cell Phone

(###)

###

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Contact 2 Home Phone

(###)

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Contact 2 Work Phone

(###)

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Pick Up Information

What time would you like him/her dismissed?

If before end of program

Will the child walk home alone?

Authorized Pick Up Person 1

First Name

Last Name

Pick Up Person 1 Relationship

Pick Up Person 1 Cell Phone

(###)

###

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Pick Up Person 1 Home Phone

(###)

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Authorized Pick Up Person 2

First Name

Last Name

Pick Up Person 2 Relationship

Pick Up Person 2 Cell Phone

(###)

###

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Pick Up Person 2 Home Phone

(###)

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Does your child need someone to walk him/her to the center?

If yes, who is that person?

Are you employed?

Name of insurance company

Please enter your insurance policy number, group number and coverage date

Medications

List any medications the child takes

List any allergies

List any disabilities

Please check if any of the following applies"

Child wears glasses

Child wears contacts

Child is UNABLE to to do moderate exercises?(Example: Running, jumping, playing ball in summer temperatures for a long period of time)

If your child is unable to participate, which would you prefer?

Please indicate that you are willing to adhere to the terms & conditions (below)

I agree

Terms & Conditons

I/we authorize that medical treatment and attention is provided for my child at my expense if it is required while attending the program.

Participants are not allowed to use the telephone. If you need to make different pick up arrangements for a particular day, call the office, visit the office, send a letter, or pick up child at bus stop.

I certify that all statements made on this application are true and correct. I authorize any individual, company, organization or institution to release any and all information concerning statements made by me in this application and do hereby release all parties and individual connected therewith from all liabilities for any damages whatsoever incurred in furnishing such information. I agree and understand that any deliberate misstatement or omission of material facts may disqualify my child from attending the program.

As necessary, pictures of activities will be taken to memorialize events; we reserve the right to use the pictures at our discretion. Your signature authorizes us to use the photos, including use on our website.

The undersigned represents that I am the legal appointed or natural guardian of the aforementioned person who is under the age of seventeen (17) years.