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Orangewood After School Program

After School Program

Orangewood After School Program Application Form

You must complete a new application for each student.

Parent/Guardian Information

Parent/Guardian's Name?*

Answer required for "Parent/Guardian's Name?"

Parent/Guardian's Email Address? *

Answer required for "Parent/Guardian's Email Address? "

Student Information

Student's Name?*

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Student's Birthday? *

Answer required for "Student's Birthday? "

Student's Grade? *

Answer required for "Student's Grade? "

Student's Address? *

Answer required for "Student's Address? "

What city do you live in? *

Answer required for "What city do you live in? "

What is your zip code?*

Answer required for "What is your zip code?"

Name of first parent/guardian? *

Answer required for "Name of first parent/guardian? "

First parent/guardian's daytime phone number? *

Answer required for "First parent/guardian's daytime phone number? "

First parent/guardian's evening phone number?*

Answer required for "First parent/guardian's evening phone number?"

Name of second parent/guardian? (if applicable)

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Second parent/guardian's daytime phone number?

Answer required for "Second parent/guardian's daytime phone number?"

Second parent/guardian's evening phone number?

Answer required for "Second parent/guardian's evening phone number?"

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

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Sibling #1 Grade?

Answer required for "Sibling #1 Grade?"

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

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

Sibling #2 Grade?

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

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Sibling #3 Grade?

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Question

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Walker (Edison Only)

Pick Up

Bus

Other:

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

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What is the 1st person's phone number?

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

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

What is the 2nd person's phone number?

Answer required for "What is the 2nd person's phone number?"

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 for "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."

I authorize staff to sign out my walker each day.

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

Answer required for "Has your student had any operations, serious medical conditions, or chronic illnesses? "

Yes

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

Answer required for "If yes, please tell about the operation, medical conditions, or illnesses."

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

Answer required for "Please list any allergies. If none, please type, \"none\""

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 for "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\"."

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

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

Yes

If yes, please specify the restrictions.

Answer required for "If yes, please specify the restrictions."

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

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

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

Answer required for "Emergency Contact #1's relationship to the student? "

Emergency Contact #1's Phone Number?*

Answer required for "Emergency Contact #1's Phone Number?"

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

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

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

Answer required for "Emergency Contact #2's relationship to the student? "

Emergency Contact #2's Phone Number?*

Answer required for "Emergency Contact #2's Phone Number?"

Do you have medical insurance?*

Answer required for "Do you have medical insurance?"

Yes

What is your medical insurance company's name?

Answer required for "What is your medical insurance company's name?"

What is your policy number?

Answer required for "What is your policy number?"

Which hospital do you prefer in case of emergency?

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Name of the insurance policy holder?

Answer required for "Name of the insurance policy holder?"

Name of family doctor?

Answer required for "Name of family doctor?"

What is your doctor's phone number?

Answer required for "What is your doctor's phone number?"

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 for "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?"

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 for "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."

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

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Signature *

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Full Name *

Date:

Confirmation Email

Confirmation Email *

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