BPS ASES Application

COLUSA UNIFIED SCHOOL DISTRICT

Colusa Unified School District

School

After School Education & Safety Program

Grade

Teacher

Student's full name

Mailing Address

Permanent Address

Mother's Name

Employer

Home Phone

Cell Phone

Work Phone

Father's Name

Employer

Home Phone

Cell Phone

Work Phone

EMERGENCY CONTACTS: List the name, Address, and phone number of two people that can be notified in case of an emergency when parent/guardian is not available.

1. Name

Relationship

Address

Phone

2. Name

Relationship

Address

Phone

Hospital Preferences

Your child will be receiving snack. Please list any known food allergies your child may have and list any health condition we should be aware of. (i.e Asthma, other allergies)

hereby authorize the staff of the Colusa After School Program to secure and sign for emergency medical care for my child at my expense, when necessary.

Parent/Guardian Signature

Clear

Date

Departure Procedures: Describe below how your child will depart from the facility on a daily basis. (i.e picked up by parent/guardian or authorized person, bicycling, walking, etc

List any persons authorized to take your child from the facility on a daily basis.

1. Name

Relationship

Address

Phone

2. Name

Relationship

Address

Phone

3. Name

Relationship

Address

Phone

The After School Program provides academic, enrichment, and recreation curriculum in a safe, secure and caring after school environment.