After School Program Registration Form

Transcription

1 To enroll your child in the Duncanville Fieldhouse AFSP Program, please complete the information below and return to the Fieldhouse Front desk along with payment and a completed registration packet. CHILD INFO: Last Name: COPY OF DRIVERS LICENSE NEEDED! First Name: DOB: AGE: SEX: M or F Nickname: CHILD INFO: Last Name: First Name: DOB: AGE: SEX: M or F Nickname: School & Transportation Information: School Attending: Teacher s Name: Payment Options: Cash-Check-Money Order- Credit Card PARENT/GUARDIAN INFO: Last Name: Address: First Name: City/State: Zip: Work #: Cell #:

2 Participation Liability Waiver & Medical Emergency Authorization Form My child, has my permission to participate in the Duncanville Fieldhouse activities, field trips and special events during the After School Program, Summer Camps, Winter Break and Spring Break Day Camp programs sponsored by the Duncanville Fieldhouse. Participation is defined to include field trips, as well as daily Fieldhouse events. I hereby release, discharge and waive all claims arising out of my child s participation in all Duncanville Fieldhouse programs, whether caused by negligence, breach of contract or otherwise, which I may ever have against the City of Duncanville, or its officers, to secure medical care for my child/children in the event of injury and in my absence. In the event of injury, I hereby absolve and hold harmless the City of Duncanville and its officers from claims arising from said injury or from claims arising from said medical care for said injury. If my child/children leave the premises during any of the designated program hours, the City of Duncanville will not be held accountable for the health and safety of my child/children. I waive all claims against Duncanville Fieldhouse (DFH) and agree to abide by all the rules of DFH. I, release, discharge, covenant not to sue and agree to indemnify, save and hold harmless DFH from all liability claims, demands, losses or damages caused or alleged to be caused in whole or in part by negligence of DFH or otherwise. I further agree that if, despite this release, I make a claim against DFH, I will indemnify, save and hold harmless DFH from any litigation expenses, attorney fees, loss liability, damage or cost that may incur as a result of any such claim. I agree that my photo may be used in the future DFH publicity. All Payment Transactions are Final. NO Refunds will be made.

3 Rules My child, hereby agrees to follow all of the Duncanville Fieldhouse rules written on the list below. I have gone over each rule individually with my child and he/she fully understands that as a result of any participant s misconduct can lead to suspension, expulsion, and other disciplinary actions. These are of violations that can lead to suspension or other disciplinary actions. It is critical that each child understands the expectations that the City of Duncanville holds for all participants. All rules will be strictly enforced. Rules and Violations 1. Actions that could result in injury of any member/patron 2. Activating the alarm by opening Gym door to exit when there is no emergency 3. Arguing 4. Being in unauthorized areas of building 5. Defiance of Personnel 6. Failure to follow Fieldhouse staff s instructions 7. Fighting/Play Fighting 8. Harassment 9. Leaving equipment unattended for staff to pick up 10. Littering 11. Misuse of equipment 12. Physical assault to staff 13. Possession of weapons 14. Profanity 15. Smoking 16. Spitting and/or biting 17. Theft 18. Vandalism or abuse to building, property or equipment 19. Violation of Fieldhouse policy If a child is suspended at anytime there will be no refunds issued

4 Child s name Emergency Care Form Parent/Guardian name Home # Cell # Telephone number where you can be reached during after school program hours: Emergency contact person s name, telephone number and relationship to child: Medical facts we should be aware of: Doctor s Name: Office #: Please provide copy of front/back of insurance card I hereby state that City of Duncanville is not responsible or liable for any injury, illness, preexisting injuries, recurrence or undisclosed injuries or the administration of any medication of the above individual. Furthermore the law requires that parental permission be obtained for operative procedure may be carried out in the event of an emergency without delays to operative procedures. No operation will be performed except in emergency, without parents being contacted and fully informed.

5 AUTHORIZATION TO ADMINISTER MEDICATION I, the undersigned, being the parent or legal guardian of a minor, do hereby authorize the City of Duncanville s Parks and Recreation Department, to administer the below specified medication/s to the minor named herein at the times and in the dosage written below: Name of Medication Times to be given Dosage Please add any special instructions: AUTHORIZING PARENT/GUARDIAN Name: Address: City/State: Zip: Cell #:

6 Pick-up Policies and Procedures Late fees are as follows (Pick up times are from 3:45 pm-6:30 pm) 1 st Late Pick up 1 to 15 minutes late - $5 15 to 30 minutes late - $10 2 nd Late Pick up 1 to 15 minutes - $10 15 to 30 minutes - $15 If caregiver is late picking up child 3 times throughout the week, that child will not be allowed to come back to the program and no refunds will be given. Late fee payments are due the day they incurred. All payment must be made at front desk. Child/ren will not be allowed to participate in program until late fees are paid in full. No refunds will be issued for any reasons. Photography/Video Release This is an agreement between you and the City of Duncanville/ Duncanville Fieldhouse regarding your child s participation in our activities. The City of Duncanville (DFH) activities may be photographed or videotaped occasionally. You hereby irrevocably grant the City of Duncanville (DFH) perpetually, exclusively, and from all media throughout the world (including print, nontheatrical, home video, CD-ROM, internet and any other advertising medium presently in existence or invented in the future), the right to use and incorporate (alone or together with other materials), in whole or in part, photographs or video footage taken as a result of your child s participation in the City of Duncanville s, (DFH) activities.

7 After School Program Registration PROGRAM CONSENT FORM I agree to record the time and my signature on the attendance sheet each time I drop off and/or pick up my child. I agree to call the Duncanville Fieldhouse site to inform the staff whenever my child will be absent. I confirm that my child is in good health, able to participate in all activities unless otherwise indicated on the Child Information Form. I understand that my child will be offered snacks daily, and unless I specify in writing otherwise, he/she may eat those snacks. I understand that if my child has allergies, I must provide information on those allergies to the Duncanville Fieldhouse staff. I agree to assume full responsibility for any damage to person or property caused by my child. I agree that if the behavior/ health of my child necessitate sending him/her home, I (or someone on my emergency contact list) will immediately pick up my child from care. I agree to keep my contacts information up to date. I understand that if my child has a persistent pattern of negative behavior and interventions have not been successful, I may be asked to remove my child from the Duncanville Fieldhouse After School Program. I understand that after 6:30 pm I must pay a late fee of $5 for the first 15 minutes and $10 for the time past 15 minutes, which my child is left in care. If tardiness becomes chronic offender may be dis-enrolled. I have read, understood and agreed to all of the above. Parent/Guardian Name: