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After-School program at Calwa Park, You can Contact Tee at 1-909-332-0276

YOUTH WITH VISION ON A MISSION (YVOM)

After-School  Program

2017-2018 School Year

 

 

REGISTRATION FORM

 

 

PARTICIPANT INFORMATION Please type or print legibly.                                                                         

 

Last Name:                                                             First Name:                               ___________ 

 

Gender: ¨ Female      ¨  Male                   Age: _       T-Shirt Size____________

 

School:                                                                                                                                                                      

 

Grade attending for year 2017-2018: _____________________

   

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          Tuesday                      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:                                              

 

Lunch:  Light Snacks will be provided but If you will be sending your child’s lunch and or snack, please be sure that your child’s lunch is clearly marked with your child’s name and last name.  Glass bottles/containers are not allowed.

 

Contact Information

For more information, contact Tee Mixon, Program Director at

909-332-0276

Emails: (redacted)

 

SIGNATURE OF PARENT OR GUARDIAN                                                       DATE           

 

I understand that the 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:

  • 2.45PM for Full Session

Pick up time:

  • 6:00PM for full session
  • 4:30PM for partial session
  • A $5 fee will be charged for every minute late after a 10-minute courtesy wait.

 

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 YVOM After-School and TEE 4 WOMEN INC., 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 TEE 4 WOMEN INC., 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 TEE 4 WOMEN INC., 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 TEE 4 WOMEN INC., and Calwa Recreation Park District, including any event sponsored or sanctioned by TEE 4 WOMEN INC., and or travel to and from such activities.

 

I understand that TEE 4 WOMEN INC., 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 TEE 4 WOMEN INC., or its scheduled program and that TEE 4 WOMEN INC., 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___________