After-School program at Calwa Park,
Calwa Recreation Park After-School Tutoring Program
2019-2020 School Year
REGISTRATION FORM
PARTICIPANT INFORMATION Please type or print legibly.
Last Name: First Name: ___________
Gender: ¨ Female ¨ Male Age: _
School:
Grade attending for year 2019-2020: _____________________
Home address:
City: State/Province: Postal/Zip Code:
Country: Telephone: cell:
Parent email:
(Include area code with telephone)
After School Schedule – 3:00 PM – 6:00 PM
Days that your child will be attending After School (Please circle days)
Monday Wednesday Thursday Friday
Mother’s name: Father’s name:
Mother’s Day phone: Father’s Day phone:
Mother’s cell: Father’s cell: _________________
Person’s Authorized to pick up child: ___________________________________________________(Please Note: Everyone picking up children will be asked for your release password or for government issued photo
ID. RELEASE PASSWORD: _______________________________________
Other Dismissal Arrangements_________________________
Your child will not be allowed to leave the program site with anyone not listed below. You can remove or add people to this list at any time by filling out the Change of Information form (available at your program site).
Emergency contact*: Relationship: Phone:
Emergency contact*: Relationship: Phone:
Emergency contact*: Relationship: Phone:
Specify any of your child’s health problems:
Is your child on any medication? No Yes If so, please specify:
Contact Information
For more information, contact Gunner Santos, Activities Coordinator at (559)264-6867
Emails: gunner@calwarecreation.org
SIGNATURE OF PARENT OR GUARDIAN DATE
I understand that my child’s position at the After School program is on a first come first serve basis after the quota is filled, my child will be on the waiting list. Any child that misses more than 2 weeks per month of unexcused absence will be dropped. Please do your best to ensure that your child attends regularly as scheduled
SIGNATURE OF PARENT OR GUARDIAN DATE
DROP OFF AND PICK UP TIMES
Drop off time:
- 3:00 PM
Pick up time:
- 6:00 PM
REQUIRES PARENT’S SIGNATURE:
You have our permission, in the event of an emergency and in case we are unavailable, to authorize any physician, nurse practitioner or medical personnel to examine, interview, test and if necessary, treat my child_______________________________________________ as they may deem advisable.
Parent/Legal guardian name________________________________________________Date_______________
Parent/Legal guardian Signature_____________________________________________Date_______________
Student Allergies________________________________________________________________
Student Medical Problems_______________________________________________________
Doctor______________________________Phone number_____________________________
Insurance carrier______________________Policy number____________________________
Who is Legally responsible for the student? _______________________________________
I hereby give permission to Calwa After-School, to photograph and/or videotape the student for educational or promotional purposes. ________ (Initial)
PARENT STATEMENT
I hereby state that (Child’s name) ___________________________________________ is in good mental and physical health condition to participate in the activities provided by Calwa Recreation Park District including but not limited to all aspects of cheerleading, tumbling, and dance training, baseball, basketball, soccer and or competition. I am fully aware that any activity involving motion, height or athletic activity creates the possibility of serious injury. I hereby release ., its employee and its staff from liability to the above-named athlete, of the person claiming through him/her, arising from injury to the person or property of the above-named athlete occurring in the premises of and Calwa Recreation Park District, including any event sponsored or sanctioned by, and or travel to and from such activities.
I understand that Calwa Recreation Park District. has the right to deny admittance to any student not meeting the standards of the program as it sees fit. I also agree not to hold these parties responsible in the event that my son/daughter/child engages in inappropriate conduct (including, but not limited to disruptive or volatile behavior in or out of After-School, etc.) or becomes involved in any activity or with any persons not associated with Calwa Recreation Park District., or its scheduled program and that Calwa Recreation Park District., has the right to send him/her home for inappropriate conduct. I further attest that the information contained in this application is correct to the best of my knowledge. In addition, I have agreed to the policy and procedure statement and agree to comply.
Parent Signature_____________________________________________Date___________