Wccusd After School Enrichment Program

WCCUSD AFTER SCHOOL ENRICHMENT PROGRAM

I give my child permission to participate in the After School Program.

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Student’s Name Grade Room Date of Birth

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Parent/Guardian’s Name (Please print) Signature Today’s Date

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Home Address City Zip

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Home Phone Work Phone Cell Phone

In case of emergency please contact:

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Name Relationship Phone

Does your child have health coverage? _____Yes _____No

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Name of Medical Insurance Policy/ Insurance #

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Medical History that may be of importance Medication Student is taking

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List any Allergies

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Name of Child’s Doctor Telephone

*In case of an emergency involving my child, I give permission for the After School Program staff to seek emergency medical treatment for my child and to act as guardian in permitting medical treatment if unable to reach me.

I understand that all emergency and/or medical costs are my responsibility.

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Parent/Guardian Name Signature Date

*I understand the West Contra Costa Unified School District assumes no responsibility or liability for injuries/illnesses of my child. I further understand that I hold the West Contra Costa Unified School District, its officers, agents, employees, and volunteers harmless from any and all liability or claims which may arise out of my child’s participation in the After School Program.

Signature of Parent/Guardian ______Date ______

As parent/guardian, I understand that the After School Program will begin immediately after school is out and will end by 5:30 p.m. on regular days and 5:00 p.m. on minimum days. In order to be released to go home from the program, students MUST be signed out by the parent/guardian or by one of the individuals listed below.

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Parent/Guardian Signature Date

When I am unable to pick my child up, I give permission to the following people to pick up my child

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Name/Relationship Phone Number

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Name/Relationship Phone Number

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Name/Relationship Phone Number

*REMEMBER: Please pick up your child on time. The program ends promptly at 5:30 p.m. on regular days and 5:00 p.m. on minimum days. If students are not picked up by these times, After School Program staff will have no choice but to contact law enforcement or other authorities to pick them up. After School Program doors are open until 6p.m.

Please note: Excessive tardiness in picking up your child may result in his/her dismissal from the program.

I give permission for the After School Program Staff to review my child’s school data (test scores, report cards and other measures), for the purpose of assessing the academic effectiveness of the After School Enrichment Program. I also give permission for After School Program staff to monitor my student’s progress and to give my child evaluation surveys to find out if services are helpful for my child.

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Parent/Guardian Signature Date

During your child’s attendance in the After School Program, s/he may be participating in an activity that is being photographed or videotaped; these photographs/video recordings may be used for promotional purposes.

My child ___may ___may not be photographed/videotaped by the program for promotional purposes.

*As parent/guardian, I understand that I hold West Contra Costa Unified School District, its officers, agents, and employees harmless from any and all liability or claims which may arise out of or in connection with my child’s being photographed or videotaped while participating in the After-School Program.

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Parent/Guardian Signature Date

I request early release of my child from the After School Program at ______o’clock p.m.

(please check reason)

q  I am concerned for my child’s safety in returning home after dark.

q  I am unavailable to pick my child up after this time.

q  Other: ______

q 

*As parent/guardian, I understand that I hold West Contra Costa Unified School District, its officers, agents, and employees harmless from any and all liability or claims which may arise out of or in connection with my child’s early release from the After-School Program.

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Signature of Parent/Guardian Date

If I arrive later than the dismissal time or am unable to pick up my child after the After School Program, my child has permission to follow the procedure marked below:

q  I give my child permission to walk home or use public transportation unsupervised to return home.

*As parent/guardian, I understand that I hold West Contra Costa Unified School District, its officers, agents, and employees harmless from any and all liability or claims which may arise out of or in connection with the After School Program pick up policy.

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Signature of Parent/Guardian Date