Choices Afterschool 25-26

Choices 2025-26 Registration Form
Child Information*
School Information*
Address

Street Address

Street Address Line 2

CityState / 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 offering during Choices? Performance Date TBD*
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.)*

YesNo
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.*

YesNo
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.*

YesNo
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*
Medication Authorization
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*
Town of Houlton Ski & Snow Shoe Trailer Organization/Participant Release Form
Participation in this activity may involve risk of injury (including disability or death). As the Organization (AABA) in charge of the Winter Sports trailer, I am aware of these hazards and my ability to oversee participants. I hereby agree to release, discharge &hold harmless the Town of Houlton, Houlton Parks & Recreation Department, and its’ employees, from liabilities, which may occur to our participants while participating in this activity. I understand that participation in any recreational or sports activity involves risks. I understand the Town of Houlton does not provide accident/medical insurance for this activity.
Participant Information*
Please check here if they can participate on all of the dates the trailer is available.

Yes
Parent /Guardian Signature

Clear
Today's Date

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Date
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Choices 2025-26 Registration Form

Medication Authorization

Town of Houlton Ski & Snow Shoe Trailer Organization/Participant Release Form