After School Program Registration

Participant Name (Child):

First Name Last Name

DOB of Child:

Date

Age of Child as of August 2022

Grade level Fall 2022

School

Teacher's Name and Room Number (if you know yet)

What time does your child get out of school on regular days?

: Hour Minutes AM/PM Option

What day is early release day at your child's school?

What time does your child get out of school on early release days?

: Hour Minutes AM/PM Option

Cell phone number of child (if applicable):

Area Code Phone Number

Parent or Guardian 1 Full Name:

First Name Last Name

Does the child live full time with parent or guardian 1? If no, please describe when the child stays with parent or guardian 1.

Parent/Guardian 1 Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Relationship(s) of parent or guardian 1 to the child (mother, father, etc.)

Cell phone number of parent/guardian 1

Area Code Phone Number

Work phone of parent/guardian 1

Area Code Phone Number

Email for parent/guardian 1

example@example.com

Parent or Guardian 2 Full Name:

First Name Last Name

Does the child live full time with parent or guardian 2? If no, please describe when the child stays with parent or guardian 2.

Parent or Guardian 2 address Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Relationship(s) of parent or guardian 2 to the child (mother, father, etc.)

Cell phone of parent/guardian 2

Area Code Phone Number

Work phone of parent/guardian 2

Area Code Phone Number

Email for parent/guardian 2

example@example.com

AUTHORIZED PERSON 1: Please list the full name of the first person authorized to pick up your child.

First Name Last Name

Phone Number of authorized person 1:

Area Code Phone Number

AUTHORIZED PERSON 2: Please list the full name of the second person authorized to pick up your child.

First Name Last Name

Authorized person 2 phone number:

Area Code Phone Number

AUTHORIZED PERSON 3: Please list the full name of the third person authorized to pick up your child.

First Name Last Name

Authorized person 3 phone number:

Area Code Phone Number

AUTHORIZED PERSON 4: Please list the full name of the fourth person authorized to pick up your child.

First Name Last Name

Authorized person 4 phone number:

Area Code Phone Number

EMERGENCY CONTACTS: Please list the full name and phone number for who who we can contact if the parents or guardians cannot be reached. If this is the same as the authorized pick up people, so state.

Medical Insurance Carrier

Name of Insured

Policy Number

Group Number

Name of Primary Care Physician:

Phone number of Primary Care Physician

Area Code Phone Number

Name of Dentist:

Phone Number of Dentist:

Area Code Phone Number

Does your child take medication?

yes no

If your child takes medication, please specify with details.

Does your child have asthma?

Yes No

Does your child carry an inhaler for their asthma?

Yes No

Has your child been diagnosed with ADD or ADHD?

Yes No

Is your child allergic to any of the following? Please select all that apply

Bee Stings Animals Trees, grasses, pollen Foods My child does not have allergies to bees, animals, trees, grasses, pollen or foods.

If you answered yes to any allergies, please describe the reaction and the severity of the allergies that you indicated.

Does your child carry an epipen?

Yes No

Are there any other health conditions or information that we should know about? If so, please describe below.

PHOTO/VIDEO RELEASE SANTA CRUZ LEARNING CENTER MAY USE THE ABOVE LISTED PARTICIPANT’S PHOTO FOR PROMOTIONAL PURPOSES. DOES SANTA CRUZ LEARNING CENTER HAVE PERMISSION TO USE PHOTOS AND VIDEOS OF YOUR CHILD?

Yes No

Please download and complete the membership payment agreement form here

Once your payment agreement form is complete, please scan it or take a photo of both pages and upload it below.

*If you are not able to complete this process, you can text or email me a scan of the payment form at 831-331-5611 or santacruzlearningcenter@gmail.com

Upload completed payment membership agreement form here

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By signing this document I (we) agree to the following terms: In case of illness or accident, Santa Cruz Learning Center, Inc, is authorized to secure emergency medical treatment at my expense. The Santa Cruz Learning Center reserves the right to dismiss any participant who does not show respect for the facility, including but not limited to property, equipment, policies, other members, volunteers, and staff. Members who are dismissed will not be given a refund of fees paid. The Santa Cruz Learning Center assumes no responsibility for personal property. By signing this Enrollment Form, I (we) hereby waive any and all claims against Santa Cruz Learning Center. I understand that the use of the facilities services with Santa Cruz Learning Center may involve the risk of bodily injury or property damage and I agree to assume any such risks. I understand that it is up to me to consult physicians and other professionals to make sure that the child registered above can safely participate in activities and events hosted by Santa Cruz Learning Center. I also understand and agree that by signing this Agreement, I am giving up my (or the minor for whom I sign) right to make any claim against Santa Cruz Learning Center, its agents, employees, and volunteers, including the right to sue them, for bodily injury or property damage or any other loss that I might suffer while using Santa Cruz Learning Center services, except as limited by law.

As the parent or guardian of the child, I am registering, I fully acknowledge and understand all of the rules and policies stated in this packet and agree to abide by them.

*

Clear

Name of person signing this registration form

First Name Last Name

After School Program Registration

Information for Parent or Guardian 1

Information for Parent or Guardian 2

Authorized Persons

Medical Insurance Information

Health Information

RELEASE SECTION