Choices Afterschool 2021-22

Child Information *

School Information *

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Mom/Guardian *

Dad/Guardian *

Allergies/Medical Concerns (Write none if none) *

Emergency Contact *

People Aurthorized to Pick Up Your Child, Not You *

People NOT Aurthorized to Pick Up Your Child (Write N/A if this does not apply) *

Terrific Tuesday Musical Drama. Is your child interested in participating in the Terrific Tuesday Musical Drama offered during Choices? If so, please check the appropriate musicals. If not, please mark Not Interested. *

Choices and their partner agencies (such as 4-H, ACAP, etc.) program have permission to use photos of your child in educational or promotional materials (such as Facebook, brochures, etc.)? (There is no cost.)

Yes No

Town of Houlton Ski & Snow Shoe TrailerOrganization/Participant Release Form: Participation in this activity may involve risk of injury (including disability or death). As a parent, guardian or participant, I am aware of these hazards and my ability to participate. I hereby agree to release, discharge & hold harmless the Town of Houlton, Houlton Parks & Recreation Department,its employees, from liabilities, which may occur while participating in this activity. I understand that participation in any recreational or sport activity involves risks. I understand the Town of Houlton does not provide accident/medical insurance for this activity.

Yes No

Adopt-A-Block Release Participation in this activity may involve risk of injury (including disability or death). As a parent, guardian or participant, I am aware of these hazards and my ability to participate. I hereby agree to release, discharge & hold harmless Adopt-A-Block and Military Street Baptist Church, its employees, from liabilities, which may occur while participating in this activity. I understand that participation in any recreational or sport activity involves risks. I understand that Adopt-A-Block or Military Street Baptist Church does not provide accident/medical insurance for this activity.

Yes No

Please read and place your name below: I understand that the Choices After School Program is a FREE program. These services are possible through grants and community funding. I will keep my contact information updated so the Choices program can reach me. I have read the above risk of injury information and agree with them *

Today's Date

Date

Choices 2021-22 Registration Form