DeSoto ISD Eagles Nest

DeSoto ISD Eagles Nest

2021-2022 School Year. For In-Person Students Only
Participant Information
Student's Name *

First Name Last Name
Gender

Male Female
Date of Birth *

Month Day Year
Date
Age *
Shirt Size *
Seats Available *
School *
Number of Siblings Attending
Current Grade Level *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Parent Email *
example@example.com
Please list any ADA Accommodations needed

Parent Information
Mother's Name

First Name Last Name
Mother's Phone
Please enter a valid phone number.
Father's Name

First Name Last Name
Father's Phone
Please enter a valid phone number.
Person's Authorized to Pick up Child (ID will be required.) *
Other Dismissal Arrangements
Emergency Contact Name *

First Name Last Name
Emergency Contact Relationship *
Emergency Contact Phone Number *
Please enter a valid phone number.
Specify any of your child's health problems:
Is your child on any medication? *

Yes No
If yes, specify...
Are there any custody issues that DeSoto ISD Eagles Nest should be aware of? *

Yes No
If yes, specify...

My child will be picked up by a parent/authorized person (Parent/Authorized Pick-Up Only) *

Yes
I certify that the information provided on this form is true and actual. I understand that the information that I have provided is subject to review by school and DeSoto ISD staff.
SIGNATURE OF PARENT OR GUARDIAN *

Clear
*Meals/Snacks: will be provided by our afterschool enrichment program aligned with TDA Texas Department of Agriculture.

Tuition: Free

Contact Information
For more information, contact Andrae Rhyne (972) 223-6666 x8337
Emails: andrae.rhyne@desotoisd.org

DeSoto Eagles Nest TIMES
Transition from school to afterschool:
- 3:15 pm to 3:30 pm
- 3:30 pm - Afterschool In Session
Pick up time:
- 5:30 pm – 6:00 pm
- A $1 fee will be charged for every minute late after a 5-minute courtesy wait.
You have our permission, in the event of an emergency and in case we are unavailable, to authorize any physician, nurse practitioner or medical personnel to examine, interview, test and if necessary, treat my child First Name Last Name as they may deem advisable
Parent/Legal Guardian Name *

First Name Last Name
Date

Month Day Year
Date
Parent/Legal Guardian Signature *

Clear
Date

Month Day Year
Date
Student Allergies
Student Medical Problems
Doctor

First Name Last Name
Doctor Phone Number
Please enter a valid phone number.
Insurance Carrier:
Policy Number:
Who is Financially Responsible for the Student?
I hereby give permission to DeSoto Eagles Nest to photograph and/or videotape the student for educational or promotional purposes. *

I hereby state that (after schooler name) First Name* Last Name* is in good mental and physical health condition to participate in the activities provided by DeSoto Eagles Nest, including but not limited to all aspects of cheerleading, tumbling, and dance training, baseball, basketball, soccer and or competition. I am fully aware that any activity involving motion, height or athletic activity creates the possibility of serious injury. I hereby release DeSoto ISD, its employee and its staff from liability to the above-named student, of the person claiming through him/her, arising from injury to the person or property of the above-named student occurring on the premises of DeSoto Eagles Nest, and DeSoto ISD, including any event sponsored or sanctioned by DeSoto Eagles Nest and or travel to and from such activities.

I understand that DeSoto Eagles Nest, has the right to deny admittance to any student not meeting the standards of the program as it sees fit. I also agree not to hold these parties responsible if my son/daughter/child engages in inappropriate conduct (including, but not limited to disruptive or volatile behavior in or out of after school programs, etc.) or becomes involved in any activity or with any persons not associated with DeSoto Eagles Nest, or its scheduled program and that DeSoto Eagles Nest, has the right to send him/her home for inappropriate conduct. I further attest that the information contained in this application is correct to the best of my knowledge.

I understand that all participants, including those authorized to pick-up students, are expected to be respectful to all staff and other participants. I understand the person I authorized to pick-up my child must be at least eighteen-year-old.

I, the undersigned, in consideration of participation in the program listed above, agree to indemnify and hold the DeSoto Eagles Nest and DeSoto ISD, and release its employees and agent from any and all liability for any injury or loss which may be suffered by the below named individual(s) arising out of or in any way connected with participation in the above program.
Parent/Guardian Signature *

Clear
Date

Month Day Year
Date
Should be Empty:

DeSoto ISD Eagles Nest

Participant Information

Parent Information