Choices Afterschool 22-23

Choices 2022-23 Registration Form
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) *
Does Choices (AABA) and their partner agencies have permission to use photos of your child in educational or promotional materials (such as Facebook, brochures, etc.)? (There is no cost.)

Yes No
Does the Choices program have permission to transport your child during the current school year? (Choices will give advance notice of all off-site field trip details.

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 *
I, (fill in name)blanks hereby authorize adult workers at Choices Afterschool Program at the Military Street Baptist Church to give my child (fill in child's name)blank over-the-counter medicine (i.e. Tylenol/Ibuprofen) on an as needed basis.   Yes   No
In case a parent/guardian or the emergency contact cannot be reached: I authorize adult workers to secure medical or dental care; which may include but not limited to ambulance, x-rays, examination, anesthetic, medical or dental diagnosis in the event of illness or injury while under the supervision of the staff and volunteers of the Choices Program. I shall pay for all such expenses and will in no way hold Adopt-A-Block of Aroostook, Military Street Baptist Church, or its representatives responsible for any financial obligation.   Yes   No
Signature
Today's Date

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Choices 2022-23 Registration Form