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___________