Shining Stars Afterschool Program

Transcription

1 Shining Stars Afterschool Program Monday-Friday 3:45-7:15 pm $40 per week/1st child $30 per week/2nd child *$36 for 3-Day Drop-In *Each Child* Games Crafts Movies Sports Homework Assistance Daily Snack Provided Duncanville Rec Center 201 James Collins Blvd.

2 AFSP Registration Form To enroll your child in the Duncanville Recreation Center AFSP Program, please complete the information below and return to the Recreation Center Front desk along with payment and a completed registration packet. COPY OF DRIVERS LICENSE NEEDED! Payment options: Cash-Check-Credit Card (Amex, Visa, MasterCard, Debit) CHILD INFO: Last Name: First Name: DOB: Age: Boy Girl Nickname: CHILD INFO: Last Name: First Name: DOB: Age: Boy Girl Nickname: School &Transportation Information: School attending: Teacher s Name: How will your child get to the Duncanville Recreation Center? If your child is riding a bus, please provide the transportation service name, contact name and phone #: PARENT/GUARDIAN INFO: Last Name: First Name: Address: City: State: Zip: Work/Home #: Cell #: Signature Date

3 School Year AFTER SCHOOL PROGRAM Participation Liability Waiver & Medical Emergency Authorization Form My child, has my permission to participate in the Duncanville Recreation Center 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 Recreation Center. Participation is defined to include field trips, as well as daily recreation events. I hereby release, discharge and waive all claims arising out of my child s participation in all Duncanville Recreation Center programs, whether caused by negligence, breach of contract or otherwise, which I may ever have against the City of Duncanville and its officers, employee or agents. I further authorize the Duncanville Recreation Center, 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 Recreation Center and agree to abide by all the rules of Duncanville Recreation Center, release, discharge, covenant not to sue and agree to indemnify, save and hold harmless Duncanville Recreation Center from all liability claims, demands, losses or damages caused or alleged to be caused in whole or in part by the negligence of Duncanville Recreation Center or otherwise. I further agree that if, despite this release, I make a claim against Duncanville Recreation Center, I will indemnify, save and hold harmless Duncanville Recreation Center 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 Duncanville Recreation Center publicity. *All payment transactions are final. No refunds will be made.* Parent/Guardian signature: Date:

4 School Year AFTER SCHOOL PROGRAM Authorization for Pick-up Child s name Parent/Guardian name Home phone cell phone Telephone number where you can be reached during after school program hours: 1 2. Emergency contact person s name, telephone number and relationship to child: I hereby authorize the person(s) listed above to sign-out my child from the care of the Duncanville Recreation Center Afterschool Program. 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 Recreation Center and agree to abide by all the rules of Duncanville Recreation Center. I, release, discharge, covenant not to sue and agree to indemnify, save and hold harmless Duncanville Recreation Center from all liability claims, demands, losses or damages caused or alleged to be caused in whole or inpart by the negligence of Duncanville Recreation Center or otherwise. I further agree that if, despite this release, I make a claim against Duncanville Recreation Center, I will indemnify, save and hold harmless Duncanville Recreation C enter 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 Duncanville Recreation Center publicity. Parent/Guardian signature: Date:

5 School Year AFTER SCHOOL PROGRAM Emergency Care Form Child s name Parent/Guardian name Home phone cell phone Telephone number where you can be reached during after school program hours: 1 2. Emergency contact person s name, telephone number and relationship to child: Medical facts we should be aware of: (Explain) Doctor s name: Office phone: Health Insurance Provider Name on Policy Provider phone: Policy number: I hereby state that The City of Duncanville or Duncanville Recreation Center is not responsible or liable for any injury, illness, preexisting injuries, recurrence or undisclosed injuries or the administration of any medications of the above individual. Furthermore the law requires that parental permission be obtained for operative procedures 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. Parent/Guardian signature: Date:

6 After School 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 Recreation Center 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 or health of my child necessitates 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 Recreation Center After School Program. I understand that after 6pm 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. I understand the child of chronic offender may be dis-enrolled. I have read, understood and agreed to all of the above. Parent/Guardian name: (Please Print) Parent/Guardian signature: Date:

7 After School Program AUTHORIZATION TO ADMINISTER MEDICATION I, the undersigned, being the parent/legal guardian of a minor, do hereby authorize the Duncanville Recreation Center, 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 below. Authorizing Parent/Guardian Name: Address: City: Zip: Phone #: Signature: Date:

8 Shining Stars After-School Program Rules My child, hereby agrees to follow all of the Recreation Center 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 Recreation Center staff s instructions 7. Fighting 8. Play Fighting 9. Harassment 10. Improper Dress 11. Leaving equipment unattended for staff to pick up 12. Littering 13. Misuse of equipment 14. Physical assault to staff 15. Possession of weapons 16. Profanity 17. Smoking 18. Spitting and or biting 19. Theft 20. Use or possession of alcohol or narcotics 21. Vandalism or abuse to building, property or equipment 22. Hanging on basketball rims 23. Violation of Center policy Parent Signature Date **If a child is suspended at anytime there will be no refunds issued**

9 Shining Stars After-School Program Pick-up Policies and Procedures Late fees are as follows (Pick up times are from 3:15pm-7:15pm): 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 late - $ minutes late - $15 If caregiver is late picking up child 3 times through out 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. Parent s Signature Date Photography/Video Release This is an agreement between you and the City of Duncanville regarding your child s participation in our activities. The City of Duncanville activities may be photographed or video taped occasionally. You hereby irrevocably grant the City of Duncanville perpetually, exclusively, and fro 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 City of Duncanville s activities. Parent s Signature Date