AFTER SCHOOL PROGRAM SIGN UP FORM

Please complete this REQUIRED form to sign up your child (if you are having more than one child attend the program you must fill out one form per child) for the after-school program taking place at the Marvin Williams Recreation Center. Programs are available for Kindergarten through 9th grade students (please refer to the after school program flyer for the specific days and times A snack will be provided, please ensure to fil out the allergies portion of this form to let us know about any restrictions your child may have or if you will be providing their snack for them This program will end at 6pm. Please pick up your child promptly from the center at 6pm.

Students Name

Grade

Parent/Guardian's Name(s)

Parent/Guardian's Phone #(s)

Parent/Guardian's Email

example@example.com

Emergency Contact Name (Other than those listed above)

Emergency Contact Phone #(s)

AFTER SCHOOL PICK-UP AUHTORIZATION & RELEASE

I, the parent/ guardian of the child listed above, give permission for the following person(s) to pick-up my child from the after-school program. I understand that my child will only be permitted to leave with the parent/guardian or the person(s) name here unless I notify the library staff by phone at (360) 377-6000 of additional person(s) authorized to pick-up my child.

Name

Telephone

Name

Telephone

Name

Telephone

Parent/Guardian Signature

Clear

Date

PARENT/GUARDIAN PERMISSION/LIABILITY RELEASE FOR AFTER-SCHOOL PROGRAMS

I hereby give permission for, child's name listed above, to ride the bus, walk and/or get dropped off to the Marvin Williams Recreation Center to participate in the afterschool programs.

I understand staff and volunteers will supervise the programs. If a serious illness or injury develops and medical and/or hospital attention is necessary, I give permission for emergency treatments or surgery as recommended by an attending physician. I specifically release and discharge, in advance, the Marvin Williams Recreation Center, Love Me For Me, its directors, employees, and volunteers from any and all liability, whether known or unknown. I agree to accept responsibility for the risks that may occur.

I hereby agree to waive, release, and discharge all claims for damages for death, personal injury, or property damage which my child may have or which may hereafter accrue as a result of my child's participation in this program against their person or entity whether such injury or damage was foreseeable. This acknowledgement of and assumption of risk and release shall be binding upon heirs and assigns.

Parent/Guardian's Name (Printed)

Parent/Guardian's Name (Signature)

Clear

I hereby authorize release of my child's name and photograph for possible news releases concerning the Marvin Williams Recreation Center (MWRC) and/or Love Me For Me (LMFM I understand that the Marvin Williams Recreation Center and/or Love Me For Me may take photographs or videos of the program or activities in which my child is participating.

I give permission for the Marvin Williams Recreation Center and/or Love Me For Me to use photographs or videos of my child for the purpose of promoting their organizations and its services/programs in print or electronically. I give permission with the following understanding: No compensation of any kind will be paid to me or my child at this time or in the future for the use of my child's likeness.

Name of Child

Parent/Guardian's Name (Printed)

Parent /Guardian's Name (Signature)

Clear

Date Signed

Clear

PLEASE RETUNR THIS FORM TO THE MARVIN WILLIAMS RECRATION CENTER OR LOVE ME FOR ME DIRECTOR, TOVI WILKINS

For more information, contact the Marvin Williams Recreation Center (360) 377-6000 or Love Me For Me