After School Emergency Contact Form


Child's Last Name Child's First Name Age
Home Phone Number - - Birth Date(mm/dd/yyyy) Male/Female
Home Address City Zip/State

  N/A   N/A
Father's Last Name Mother's Last Name
Father's First Name Mother's First Name
Address(if different from child's address) Address(if different from child's address)
City City
Zip Zip
State State
Phone Number - - Phone Number - -
Additional Phone Number - - Additional Phone Number - -
Employer Employer

Emergency Contact

(MUST BE SOMEONE OTHER THAN MOM AND DAD AND LIVE AT A DIFFERENT ADDRESS THAN THE CHILD)
Last Name Address
First Name City
Phone Number - - Zip
Additional Phone Number - - State
Relationship  

Additional Persons Authorized to Pick Up the Child

In addition to my child's legal guardians and emergency contact listed above, I hereby authorize Powersports to allow my child to leave ONLY with the following persons. Name and telephone number are needed for each. Children will only be released to a parent or person designated by the parent/guardian after verification of ID.
Last Name First Name Phone Number --

Optional: I hereby give my consent for my child to be released to the following siblings who are under 18 years.
Name of Sibling(s)

Medical Information

List any medical problems that your child may have, such as allergies, exiting illnesses, previous serious illness, injuries, any medication prescribed for long-term continuous use, and any other information which caregivers should be aware of:
Child daycare operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA Information Line at 800-514-0301 (voice) or 800-514-0383 (TTY).

Agreements are found in the After School/Summer Camp Handbook

Authorization for Emergency Medical Attention Agreement

In the event that I cannot make arrangements for emergency medical care, I authorize the person in charge to take my child to:

School Information

My child attends the following school:
 
My child for the school year 2018-2019 will be in grade  

Immunization Agreement
I verify that my child's immunization records are on file at the school and all required immunizations and/or tuberculosis test are current. Vision and Hearing screening records are also on file.

Discipline Agreement
I have read and understand the Student Discipline Guidelines and agree to follow them in accordance to the parent handbook.

Transportation Agreement
I hereby give consent for my child to be transported to and from their school by the operation’s employees. I understand that if my child misses the Powersports Bus, Powersports WILL NOT return to the school and it is my responsibility to find transportation for my child.

Acknowledgment of Handbook
By signing my name, I agree that I have read in full the Powersports After School and Summer Camp policies and procedures and will abide by them.

Also, my signature verifies receipt of the Discipline and Guidance Policies and permits Powersports to obtain emergency medical treatment if needed.
Signature:
Date: 07/20/2018
By signing here I verify all information in this form is correct and agree to all Powersports policies and procedures.

Once your form is submitted, you must call Powersports to complete your registration