After School Activities Permission Slip
Scofield Magnet Middle School 641 Scofieldtown Road Stamford, CT 06903
By completing this form, you are allowing your child to stay after school to partake in school sponsored activities. The activities covered under this permission slip include school sponsored sports programs, academic clubs and enrichment, intramurals, and any other school sponsored activity that would require your child to remain on the premises beyond the normal school hours of operation at any designated time throughout the academic school year. In addition to the completion of this form, it is also necessary that your child completes the After School Sign-up sheet every morning during advisory for each day in which he/she plans on attending an after school activity. Failing to do so will result in exclusion from that activity for that day. Likewise, if your child completes the necessary forms but fails to attend the activity and is not excused, he/she may be prohibited from future activities for a set amount of time.
Please completely fill in this form:
Child’s Last Name First Name
Address Zip:
Grade Team Room
Advisory Teacher
Parent/Guardian’s Name:
Phone (home) (work)
(cell) email address
Are there any health conditions we should know about?
Academic Clubs and Enrichment, complete below
Club/Activity Choice #1Day
Club/Activity Choice #2Day
Club/Activity Choice #3Day
You will be told which club/activity you have been assigned by your advisory teacher.
The program begins the week of March 12 and ends May 11, 2018
If you have questions regarding clubsandenrichment only, please email Ms. D’Agostino ()
Please check all that apply for dismissal for after school activities
_____ I give permission for my child to walk home from SMMS.
_____My child will take the late bus home at 4:00pm (Monday, Tuesday, and Thursday).
_____ I will be responsible for picking up my child at 4:00pm.
Written Plan for Emergencies
I______(parent/guardian’s name) understand that in case of emergency, first aid will be administered and the parents or other designated responsible individuals will be notified. No care beyond first aid (defined as immediate, temporary care given in case of accident or illness) can be given by ROSCCO/Scofield Staff. I give permission to the ROSCCO/Scofield staff to obtain emergency medical treatment for my child. I understand ROSCCO/Scofield is not responsible for cost of emergency treatment or for medical care given by emergency medical personnel. I also understand that all expenses incurred are the responsibility of the parent.
Parent/Guardian Signature: ______Date:
Please return this form to your child’s advisory teacher as soon as possible.
Students may not remain in the building unsupervised at the end of the school day or following after school activities. The administration reserves the right to contact the Stamford Police Department or the Department of Children and Families for students who are repeatedly left unattended by parents or guardians beyond the school day.