EMS ASES application

Name

Student First NameStudent Last Name

Student Current Grade

Mother/Guardian Name

Mother/Guardian First NameMother/Guardian Last Name

Mother/Guardian Cell Phone

Mother/Guardian Work Phone

Mother/Guardian Home Phone

Father/Guardian Name

Father/Guardian First NameFather/Guardian Last Name

Father/Guardian Cell Phone

Father/Guardian Work Phone

Father/Guardian Home Phone

The emergency contacts listed below may be contacted if the parent/guardian is not available & have the authority to pick up the student from the program.

Emergency Contact 1

First NameLast Name

Emergency Contact 1 Relation

Relation

Emergency Contact 1 Phone Number

Please enter a valid phone number.

Emergency Contact 2

First NameLast Name

Emergency Contact 2 Relation

Relation

Emergency Contact 2 Phone Number

Please enter a valid phone number.

Emergency Contact 3

First NameLast Name

Emergency Contact 3 Relation

Relation

Emergency Contact 3 Phone Number

Please enter a valid phone number.

Emergency Contact 4

First NameLast Name

Emergency Contact 4 Relation

Relation

Emergency Contact 4 Phone Number

Please enter a valid phone number.

My student may sign out any time after

I give permission for my student to ( check all that apply:

Walk HomeRide Bike Home

My student may sign out any time after:

My student may sign out any time after

Parent Acknowledgement/Release Information

hours required to maintain enrollment in the program.

handbook.

I have received, read, and understand the ASES Handbook.My student is permitted to use the internet during the After School Program.My student may attend field trips during the After School Program.My student may watch PG films during the After School Program.I understand that my student must maintain the necessary attendance and attendanceI agree to document early releases according to the early release policy listed in theI understand & accept the behavior and discipline guidelines for the After School

Signature

Date