After School Program

Edison Middle School After School Program Application

You must complete a new application for each student.

Parent/Guardian Information

Parent/Guardian's Name?*

Answer Required

Parent/Guardian's Email Address? *

Answer Required

Student Information

Student's Name?*

Answer Required

Student's Birthday? *

Answer Required

Student's Address? *

Answer Required

What city do you live in? *

Answer Required

What is your zip code?*

Answer Required

Name of first parent/guardian? *

Answer Required

First parent/guardian's daytime phone number? *

Answer Required

First parent/guardian's evening phone number?*

Answer Required

Name of second parent/guardian? (if applicable)

Answer Required

Second parent/guardian's daytime phone number?

Answer Required

Second parent/guardian's evening phone number?

Answer Required

If your student has any siblings that attend the Edison School District please list here: Sibling #1 Name?

Answer Required

If your student has any siblings that attend the Edison School District please list here: Sibling #2 Name?

Answer Required

If your student has any siblings that attend the Edison School District please list here: Sibling #3 Name?

Answer Required

Question

Answer Required

Walker (Edison Only)

Pick Up

Bus

Other:

If your student is a pick up, who is the 1st person approved to pick them up?

Answer Required

What is the 1st person's phone number?

Answer Required

If your student is a pick up, who is the 2nd person approved to pick them up?

Answer Required

What is the 2nd person's phone number?

Answer Required

If your student is a walker, you must give the After School staff permission to sign them out each day in order for them to walk home. By clicking below you authorize the After School Program staff to sign our your walker each day.

Answer Required

I authorize staff to sign out my walker each day.

Has your student had any operations, serious medical conditions, or chronic illnesses? *

Answer Required

Yes

If yes, please tell about the operation, medical conditions, or illnesses.

Answer Required

Please list any allergies. If none, please type, "none"

Answer Required

Does your child have any known physical, mental, social difficulties, or other information which may affect participation and/or for which special accommodations are needed? Please specify. If none, please type, "none".

Answer Required

Does your child have any activity restrictions desired by the child, parent/guardian, or physician?

Answer Required

Yes

If yes, please specify the restrictions.

Answer Required

Name a person who can be used as an emergency contact in case the parent/guardian cannot be reached.

Answer Required

Emergency Contact #1's relationship to the student? *

Answer Required

Emergency Contact #1's Phone Number?*

Answer Required

Name another person who can be used as an emergency contact in case the parent/guardian cannot be reached.*

Answer Required

Emergency Contact #2's relationship to the student? *

Answer Required

Emergency Contact #2's Phone Number?*

Answer Required

Do you have medical insurance?*

Answer Required

Yes

What is your medical insurance company's name?

Answer Required

What is your policy number?

Answer Required

Which hospital do you prefer in case of emergency?

Answer Required

Name of the insurance policy holder?

Answer Required

Name of family doctor?

Answer Required

What is your doctor's phone number?

Answer Required

I grant permission for my child to participate and appear in still photography or audio-visual programming whether via television, film, audio tape, or electronic media for the Edison School District in connection with publicity, advertising, or promotion of the ASES program. I waive the right to control, approve, use, or reuse of such photograph or audio-visual programming. On behalf of myself, and my child, I also waive any right to fees, royalties, or other compensation which may arise from my child’s participation in the still photography or audio-visual programming under the log of the United States or any state thereof, or under the laws of any nation or jurisdiction. My consent of my child is valid for the current school year unless I notify the district in writing that my consent has been withdrawn. Do you consent to the above statement?*

Answer Required

Yes

I have read, understand, and agree to the conditions of my child’s participation in the ASES Program. I also verify that all the above information on my child is complete and accurate. I understand that reasonable measures will be taken to safeguard the health and safety of all participants. I will be notified as soon as possible in case of an emergency. In the event that I cannot be reached in an emergency, I hereby authorize transportation to a medical facility and/or the calling of a physician at my expense to provide whatever emergency medical treatment necessary. By clicking yes below, I give permission for my child to participate in the ASES Program.*

Answer Required

Yes, my child can participate in the After School Program.

No, I do not want my child to participate in the After School Program.

Signature*

Signature Required

Please fix the highlighted areas below before submitting.

Edison Middle School After School Program

Parent/Guardian Information