Enrollment Information (PLEASE PRINT)

Enrollment Information (PLEASE PRINT)

Child’s Legal Name: M/F

Date of Birth:___/___/___ Age: ___ Race: ______School:______Grade: _____

Mother/Guardian Name Occupation E-Mail

Home Address City State Zip Home Phone

Employer’s Name Work Phone Cell Phone

Father/Guardian Name Occupation E-Mail

Home Address City State Zip Home Phone

Employer’s Name Work Phone Cell Phone

Child’s Physician Name: ______Physician Phone# ______

Preferred Hospital: ______Telephone #______

Insurance Co. ______Policy # ______

Please list any medications, medical problems or disabilities that pertain to your child: ______

* * * * * * * * * * * * * * * * * * * * * * * * *

Authorization for Emergency Medical Treatment

If my child, ______, should become ill or be injured at the 21st Century P.A.L. After-School Program, I understand that the facility will: 1) contact me immediately, or 2) contact the person(s) I have designated. I give my permission for the 21st Century P.A.L. Program to contact my child’s physician and/or arrange for immediate emergency treatment. The physician and/or medical facility are authorized to administer emergency medical treatment necessary to insure the safety of my child.

Parent/Guardian Signature:______Date: ______

Please list those person(s) we may contact who are authorized by you, who can assume responsibility for your child if for some reason you, the parent(s) can not be read immediately in an emergency situation.

Name(s) Address Phone Number

1.

2.

3.

(Please complete both sides of this form)

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______

(Student Name)

My child has permission to walk home ______My child may NOT walk home _____

Transportation Home: _____ Bus (all bus riders leave school at 5:00pm

_____ Car rider ( approximate time child will be picked up ______)

My child may be picked up by the following people (include parents’ names)

Name Phone Name Phone

* * * * * * * * * * * * * * * * * * * * * * * * *

Waiver and Release Liability

In consideration of being allowed to participate in any way in the 21st Century P.A.L. After-School Program athletic/sports program, and related events and activities, the undersigned:

1.  Agree that the Director will instruct the participants that prior to participating, they should inspect facilities and equipment to be used, and if the participants believe that anything is unsafe, they should immediately advise the director or other supervisor of such condition(s) and refuse to participate.

2.  Acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability and death, and severe social and economic losses which might result not only from the actions, inactions or negligence of others, the rules of play, or the condition of the premises or of any equipment used. Further, that there may be other risks not known to us or not reasonably foreseeable at this time.

3.  Assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death.

4.  Release, waive, discharge and convenant not to sue the 21st Century or the Police Athletic League of Sarasota County, Inc., its affiliated clubs, their respective administrators, directors, agents, coaches, and other employees of the organization, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and leasees of premises used to conduct the event, all of which are hereinafter referred to as “releasees”, from any and all liability to the undersigned, his or hers or next of kin for any and all claims, demands, losses or damages on account of injury, including death or damage to property, caused or alleged to be caused in whole or part by the negligence of the releasees or otherwise.

I/WE HAVE READ THE ABOVE WAIVER AND RELEASE, UNDERSTAND THAT I/WE GIVE UP SUBSTANTIAL RIGHT BY SIGNING IT, AND SIGN IT VOLUNTARILY.

Parent/Guardian Signature Date

______

Parent/Guardian Print Name

ALL FORMS MUST BE COMPLETELY FILLED OUT AND RETURNED

WHAT: 21st Century After-School program

WHEN: Monday through Thursday, 3:15pm–5:30pm & 5:30pm on Friday

WHERE: Emma E. Booker Elementary, Ph: 361-6480, Fax: 361-6484

2350 Dr. MLK Jr. Way

WHY: To provide recreational and educational activities for children living in the local area.

WHO: Youth in grades 2nd through 5th .

GENERAL INFORMATION: This program is for children who are in need of supervision, homework assistance and activities after school. Children in the 21st Century After-School Program will meet in the Emma E. Booker Elementary cafeteria upon dismissal from school each day. Children will need to be picked up by a parent or guardian. Children must remain at the site until the time they are specified to leave. Once they leave the program, they will not be able to return for the day. These regulations are for your child’s safety.

The program runs from 3:15 – 6:00pm Monday-Thursday and 3:15 – 5:00 on Friday’s. Your child MUST be picked up by 6:00pm Mon.-Thurs. and 5:00 on Friday’s or additional fees will be assessed, $5.00 for every 15 minutes you are late. If this happens on a regular basis your child may be suspended from the program.

SIGN OUT: Parent(s) or authorized person(s) must sign your child out. You must exit your vehicle and make contact with staff personnel before retrieving your child to let them know you are taking him/her home. This is for your child’s safety. Photo ID may be required to be shown for the first couple of weeks, so please have it available.

PERSONAL PROPERTY: We are not responsible for lost, stolen or damaged items that your child brings to the program.

BEHAVIOR POLICY: There is zero tolerance for fighting. 21st Century’s goal is to provide a safe environment for your child to lean, play, and achieve while developing positive relationships. Students are expected to follow the rules, participate in activities and show respect to teachers, counselors and fellow students at all times.

ISSUES/CONCERNS: Any and all issues that concern the 21st Century After-School Program are to be brought to the program director as quickly as possible. You may also contact the Emma E. Booker Elementary office at 361-6480.

SPECIAL NEEDS: It is the responsibility of the parent to inform the program director if your child has special needs.

HOMEWORK ASSISTANCE: This program is designed to help your child get a head start on or even finish their homework before they’re picked up by their parents. If a child does not have homework for the day, they are encouraged to read an AR book. Children must provide their own school supplies. This is not a substitute for parental involvement in your child’s academic career. Assistance will be provided by a Florida Certified teacher along with homework helpers on staff.