AFTER SCHOOL ACADEMY REGISTRATION FORM

AFTER SCHOOL ACADEMY REGISTRATION FORM
This form must be completed and signed by a parent/guardian for each student prior to participating in the program. See fee schedule for program for rates at fremont.gov/asa. PROGRAM FEE IS WAIVED FOR STUDENTS ELIGIBLE FOR LUNCH ASSISTANCE PROGRAM-MUST UPLOAD CNS LETTER TO THIS FORM.
Upload CNS meal assistance letter here

Cancel of
PARTICIPANT INFORMATION
PARTICIPANT'S SCHOOL? *

BRIER CABRILLO GRIMMER
Gender

Male Female
Date of Birth *

Month Day Year
Date
Name *

First Name Last Name
Age *
Grade in 21/22 - Please note: The ASA program is offered to students in grades 2nd to 6th. *
Home Language(s)
Parent/Legal Guardian Name *
Parent/Guardian Email Address *
example@example.com
Cell Phone *
Home Phone
Work Phone
Address *

Address

Street Address Line 2

City

Zip Code
Participant's Medical Insurance Provider (Kaiser, Blue Shield, Medicaid, etc.)

The following people are authorized to pick up my child and may be called in case of emergency: *

	Name of Emergency Contact	Relationship to Child	Cell Phone	Home Phone	Work Phone
1
2
3

My child will be departing on his/her own. As this child's parent/legal guardian, I have deemed them physically and mentally responsible enough to transport themselves. I do not put any responsibility or liability on City staff to monitor the departure of my child. I am requesting to waive the sign out requirement for my child.

Yes
Please sign here only if you're allowing your child to depart on his/her own.

Clear
MEDICAL CONDITIONS

Food Allergies Skin/Sunscreen Allergies Environmental Allergies Other
Please explain & list allergies
OTHER INFORMATION
Understanding a child's background and special needs helps staff provide the best program experience for all participants, including your child. Please list any information that is important. (e.g. ADD, ADHD, Autism, learning disabilities, noise sensitivity, etc:
Acceptance into the program is determined by the following:
- Priority 1: Principal/Teacher recommendations
- Priority 2: Students currently enrolled in program (in good standing)
- Priority 3: Siblings of students enrolled under priority 1 & 2
- Priority 4: Open enrollment.
All balances must be paid before each payment deadline for students who are not eligible for lunch assistance program. All priorities are determined on a first come, first serve basis.
ASA RETURNER? *

YES NO
ELIGIBLE FOR LUNCH ASSISTANCE? *

YES NO
Parent/Guardian Name *
Signature *

Clear
Date *

Month Day Year
Date

REQUIRED PROGRAM FORMS

Please read each form in its entirety and complete all acknowledgment fields.
CITY OF FREMONT RELEASE AGREEMENT FOR ALL PARTICIPANTS

IN CONSIDERATION OF PERMISSION TO PARTICIPATE IN OR USE ANY CITY OF FREMONT (hereinafter referred to as "City") FACILITIES IN CONNECTION WITH THIS ACTIVITY, THE PARTICIPANT AGREES TO THE FOLLOWING:

1. THE PARTICIPANT HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE THE CITY OF FREMONT, ITS EMPLOYEES, OFFICERS AND AGENTS (hereinafter referred to as "releasees") from all liability to the participant, his or her personal representatives, assigns, heirs, and next of kin, for any loss, damage, or claim therefore on account of injury to the person, participant's family member, or property of the participant, whether caused by any negligent act or omission of the releasees or otherwise, while the participant or participant's family member is participating in a City activity or using any City facilities in connection with the activity.

2. THE PARTICIPANT HEREBY AGREES TO INDEMNIFY AND HOLD HARMLESS the releasees from all liability, claims, demands, causes of action, charges, expenses, and attorney fees (including attorney fees to establish the releasees' right to indemnify incurred on appeal) resulting from involvement in this activity, whether caused by any negligent act or omission of the releasees or otherwise.

3. THE PARTICIPANT HEREBY ASSUMES FULL RESPONSIBILITY FOR RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to self or participant's family member while upon City property or participating in the activity or using any City facilities and equipment, whether caused by any negligent act or omission of releasees or otherwise. The participant expressly agrees that the foregoing release and waiver, indemnity agreement and assumption of risk, are intend- ed to be as broad and inclusive as permitted by California law and that if any portion thereof is deemed to be held in- valid, notwithstanding, the balance shall continue in full legal force and effect.

I ACKNOWLEDGE THAT I HAVE READ THE FOREGOING and I am aware of the legal consequences of this agreement, including the acknowledgement that it prevents me from suing the City or its employees, agents, or officers, if I or my family member is injured or my property is damaged for any reason as a result of participation in this activity. I further acknowledge that no oral representations, statements or inducements have been made.

IF THE PARTICIPANTS ARE MINORS his or her custodial parent or legal guardian must read and execute this agreement. I hereby warrant that I am the custodial parent or legal guardian of the participants listed on the registration.
Parent/Guardian Name (print) *
Participant Name *
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

The Novel Coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and health agencies recommend social distancing and have restricted the gathering of groups.

While COVID-19 can cause mild symptoms in some individuals, it can lead to severe illness and even death in others. Adults over age 65 and people of any age with serious underlying medical conditions as defined by the CDC, may be a higher risk for more serious complications from COVID-19.

Attending After School Academy could increase your risk and your child(ren)'s risk of contracting COVID-19. The City of Fremont Community Services Department has put in place preventative measures to reduce the spread of COVID-19 consistent with the Alameda County Public Health Department Guidelines; however, the City cannot guarantee that you, your child(ren) or other program participants will not become infected with COVID-19. The City is taking precautions to prevent the spread of COVID-19 but these precautions are not guarantees that any participants will not contract COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the City of Fremont After School Academy and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 by attending the City of Fremont After School Academy may result from the actions, omissions, or negligence of myself and others, including, but not limited to, City employees, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself including, but not limited to, personal injury, disability, and death, illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)'s participation in recreation programming ("Claims" On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the City, its employees, agents, and representatives, of and from the claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of the City, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any City of Fremont After School Academy.
Name of Adult Parent/Guardian *
Signature of Adult (Parent/Guardian) *

Clear
Date *

Month Day Year
Date
Name of Student *

Photo/Likeness Release Form

I, First Name Last Name hereby authorize the City of Fremont to photograph, videotape or film me and/or my child and consent to the use of my name and/or likeness in the Recreation Guides (including the cover), 4-page Marketing Bulletin, and e-newsletters; and on Facebook, City website (www.fremont.gov), City Cable TV Channel 27, City marketing brochures, and/or any other related materials and publications.
I understand and agree that such materials, including all negatives, positives, and prints shall become and remain the sole property of the City of Fremont and I shall have no right or title to such items. I further understand and agree that these materials may be kept on file and/or used by the City of Fremont for potential future uses and further agree to release the City of Fremont from any and all liability arising from or in connection with the taking, use, publication, or dissemination of such materials.
I represent that I am a parent/guardian of the minor who has signed the above release and that in that capacity the City of Fremont has my consent and authorization to use the name and/or likeness as described above.
INITIAL HERE
Adult's Name
Signature

Clear
Children(s) Name
Email
example@example.com
Phone

ZOOM RESOURCE ACCESS

I am aware that the ASA utilizes Zoom for an online platform to facilitate collaboration and communication among students and staff.
I DO give permission for my Student to have Internet access and use Zoom for ASA program access. I DO NOT give permission for my Student to have Internet access and use Zoom for ASA program access. The Student will not be able to participate in the Virtual After School Academy and will resume enrollment when the program returns to an on-site format.
Student's Name (print)
Date of Birth

Month Day Year
Date
Parent/Guardian Signature

Clear
Date

Month Day Year
Date

ASA-PARENT AGREEMENT

Please read the 2021-2022 Parent Handbook and acknowledge the following:
I have read and understand the 2021-2022 Parent Handbook and the contents within. *

Clear
I have read and agree to abide by the attendance requirements. *

Clear
I have read and agree to abide by the dismissal policy. *

Clear
I have read and agree to abide by the behavior and discipline policy. *

Clear
I am aware that this program offers homework assistance but may not be sufficient time to complete the homework. It is my responsibility to check my child's homework for completion and accuracy. *

Clear
I will be charged $20 every 5 minutes my child is late to get picked up after 6pm. I understand payment will be due the following program date to the Site Coordinator. *

Clear
Date *

Month Day Year
Date
All signature lines must be signed in order to maintain your child's registration in the After School Academy.

ASA-STUDENT AGREEMENT
ASA-STUDENT AGREEMENT

Please review this with your child. We ask that both you and your child sign your initials in the space next to each statement and sign the bottom of the form.
1. I have read and agree with the Discipline Section. Initial *
2. I will follow all of the After School Academy (ASA) rules. Initial *
3. I will treat all members of ASA, staff & students, with respect. Initial *
4. I will treat myself with respect. Initial *
5. I will respect the environment and the property of both the Fremont Unified School District, City of Fremont, and After School Academy. Initial *
6. I will NOT hit, punch, slap, kick, pinch, or otherwise physically harm any other. Initial *
7. If I am having a problem with another member of ASA, I will try my best to talk through the problem and come up with a solution. Initial *
8. I will follow the directions that ASA Staff has given me. Initial *
9. If a staff member is talking to me, I will listen to what they have to say. Initial *
10. I will use appropriate language. Initial *
11. I will be honest. Initial *
12. I will do my best to have a positive attitude and actively participate. Initial *
13. I will do my homework during homework time. If I do not have homework or if I finish early then I will read quietly. Initial *
14. I agree to not bring my friends to ASA unless they are registered for the program. Initial *
I understand the following items listed above and agree to these conditions.
Student's Name *

First Name Last Name
Date *

Month Day Year
Date
Student Signature *

Clear
Parent/Guardian Signature *

Clear
Should be Empty:

AFTER SCHOOL ACADEMY REGISTRATION FORM

PARTICIPANT INFORMATION

OTHER INFORMATION

REQUIRED PROGRAM FORMS

Photo/Likeness Release Form

ASA-PARENT AGREEMENT

ASA-STUDENT AGREEMENT

ASA-STUDENT AGREEMENT