2024-2025 AFTER SCHOOL ACADEMY REGISTRATION FORM

2024-2025 AFTER SCHOOL ACADEMY REGISTRATION FORM
Form must be completed and signed by a parent/guardian for each student prior to participating in the program. See fee schedule for program rates. Low income families may be eligible for program fees to be waived—MUST COMPLETE ALTERNATIVE INCOME FORM AT www.fusdcafes.org.

Return this form to: Fremont City Hall, 3300 Capitol Ave., Bldg. B., Fremont, CA 94538; Attn: Raquel Christopher or email to ASA@fremont.gov
PARTICIPANT INFORMATION
PARTICIPANT'S SCHOOL?*

BRIERCABRILLOGRIMMER
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Age*
Grade in 24/25*
Parent/Guardian Full Name*
Parent/Guardian Date of Birth*

MonthDayYear
Date
Parent/Guardian Email Address*
example@example.com
Cell Phone*
Home Phone
Work Phone
Address*

Address

Street Address Line 2

CityState / Province

Zip Code
Participants Medical Insurance Provider
Kaiser, Blue Shield, Medicaid, etc.

The following people are authorized to pick-up my child and may be called in case of an emergency (please list 3 names):*

	Name of Emergency Contact	Relationship to Child	Cell Phone	Home Phone	Work Phone
1
2
3

PARENT/GUARDIAN INITIAL

I am requesting to waive the sign out requirement for my child. My child will be departing on his/her own. As this child’s parent/legal guardian, I have deemed them physically and mentally responsible enough to transport themselves. I do not put any responsibility or liability on City staff to monitor the departure of my child.
Signature

Clear
MEDICAL CONDITIONS

Food AllgergiesSkin/Sunscreen AllergiesEnvironmental AllergiesOther:
Please explain & list. If none, type N/A*
OTHER INFORMATION
Understanding a child’s background and special needs helps staff provide the best program experience for all participants, including your child. Please list any information that is important. e.g. ADD, ADHD, Autism, learning disabilities, noise sensitivity, etc. If none, please type N/A.*
Acceptance into the program is determined by the following:

Priority 1: Principal/Teacher recommendation

Priority 2: Students currently enrolled in program (good standing)

Priority 3: Siblings of students enrolled under priority 1 & 2

Priority 4: Open enrollment

All balances must be paid before each payment deadline for students who are not eligible for program waiver. All priorities are determined on a first come, first serve basis.
ASA Returner?*

YesNo
Low Income Eligible? If you select no you will be added to the monthly payment system. If you select yes, proof of letter form FUSD must be provided.*

YesNo
Parent/Guardian Name*
Signature*

Clear
Date*

MonthDayYear

CITY OF FREMONT RELEASE AGREEMENT FOR ALL PARTICIPANTS
IN CONSIDERATION OF PERMISSION TO PARTICIPATE IN OR USE ANY CITY OF FREMONT (hereinafter referred to as City”) FACILITIES IN CONNECTION WITH THIS ACTIVITY, THE PARTICIPANT AGREES TO THE FOLLOWING:

1. THE PARTICIPANT HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE THE CITY OF FREMONT, ITS EMPLOYEES, OFFICERS AND AGENTS (hereinafter referred to as “releasees”) from all liability to the participant, his or her personal representatives, assigns, heirs, and next of kin, for any loss, damage, or claim therefore on account of injury to the person, participant’s family member, or property of the participant, whether caused by any negligent act or omission of the releasees or otherwise, while the participant or participant’s family member is partici- pating in a City activity or using any City facilities in connection with the activity.

2. THE PARTICIPANT HEREBY AGREES TO INDEMNIFY AND HOLD HARMLESS the releasees from all liability, claims, demands, causes of action, charges, expenses, and attorney fees (including attorney fees to establish the releasees right to indemnify incurred on appeal) resulting from involvement in this activity, whether caused by any negligent act or omission of the releasees or otherwise.

3. THE PARTICIPANT HEREBY ASSUMES FULL RESPONSIBILITY FOR RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to self or participant’s family member while upon City property or participating in the activity or using any City facilities and equipment, whether caused by any negligent act or omission of releasees or otherwise. The partici- pant expressly agrees that the foregoing release and waiver, indemnity agreement and assumption of risk, are intend- ed to be as broad and inclusive as permitted by California law and that if any portion thereof is deemed to be held in- valid, notwithstanding, the balance shall continue in full legal force and effect.

I ACKNOWLEDGE THAT I HAVE READ THE FOREGOING and I am aware of the legal consequences of this agreement, including the acknowledgement that it prevents me from suing the City or its employees, agents, or officers, if I or my family member is injured or my property is damaged for any reason as a result of participation in this activity. I further acknowledge that no oral representations, statements or inducements have been made.

IF THE PARTICIPANTS ARE MINORS his or her custodial parent or legal guardian must read and execute this agree- ment. I hereby warrant that I am the custodial parent or legal guardian of the participants listed on the registration form.
AFTER SCHOOL ACADEMY 2024/25
Parent/Guardian Name *
Participant Name*
Signature*

Clear
Date*

MonthDayYear

INTERNET AND ONLINE RESOURCE ACCESS
I am aware that ASA utilizes computers and online platforms to facilitate collaboration and communication among students and staff.
Please select one.*

I DO give permission for my Student to have Internet and online access in the ASA program.I DO NOT give permission for my Student to have Internet and online access. The student will not be able to use program loaned iPads or Chromebooks for activities or assignment assistance.
Student’s Name (print)*
Date of Birth*

MonthDayYear
Date
Signature*

Clear
Signature Date*

MonthDayYear
Date

Photo/Likeness Release Form
I,*
Type name
, hereby authorize the City of Fremont to photograph, videotape or film me and/or my child and consent to the use of my name and/or likeness in the Recreation Guides (including the cover), 4-page Marketing Bulletin, and e-newsletters; and on Facebook, City website (www.fremont.gov), City Cable TV Channel 27, City marketing brochures, and/or any other related materials and publications.

I understand and agree that such materials, including all negatives, positives, and prints shall become and remain the sole property of the City of Fremont and I shall have no right or title to such items. I further understand and agree that these materials may be kept on file and/or used by the City of Fremont for potential future uses and further agree to release the City of Fremont from any and all liability arising from or in connection with the taking, use, publication, or dissemination of such materials.

I represent that I am a parent/guardian of the minor who has signed the above release and that in that capacity the City of Fremont has my consent and authorization to use the name and/or likeness as described above.
INITIAL HERE*
Parent’s Name*
Signature*

Clear
Children(s) Name*
Email*
example@example.com
Phone*

ASA-PARENT AGREEMENT
All boxes must be checked and form must be signed in order to maintain your child's registration in the After School Academy.*

I have read and understand the 2024-2025 Parent Handbook and the contents within.I have read and agree to abide by the attendance requirements.I have read and agree to abide by the dismissal policy.I have read and agree to abide by the behavior and discipline policy.I am aware that this program offers homework assistance but may not be sufficient time to complete the homework. It is my responsibility to check my child's homework for completion and accuracy.I will be charged $20 every 5 minutes my child is late to get picked up (after 6pm). I understand payment will be due the following program date to the Site Coordinator.
Signature*

Clear
Signature Date*

MonthDayYear
Date

ASA-STUDENT AGREEMENT
Please review these statements with your child. Both you and your child must sign at the bottom of the form confirming understanding.

1. I have read and agree with the Discipline Section.

2. I will follow all of the After School Academy (ASA) rules.

3. I will treat all members of ASA, staff and students, with respect.

4. I will treat myself with respect.

5. I will respect the environment and the property of both the Fremont Unified School District, City of Fremont, and After School Academy.

6. I will NOT hit, punch, slap, kick, pinch, or otherwise physically harm any other person.

7. If I am having a problem with another member of ASA, I will try my best to talk through the problem and come up with a solution.

8. I will follow the directions that ASA Staff has given me.

9. If a staff member is talking to me, I will listen.

10. I will use appropriate language.

12. I will have a positive attitude and actively participate.

13. I will do my homework during homework time. If I do not have homework or if I finish early then I will read quietly.

14. I agree to not bring my friends to ASA unless they are registered.

I understand the following items listed above and agree to these conditions.
Student’s Name (print)*
Student Signature*

Clear
Parent's Signature*

Clear
Signature Date*

MonthDayYear
Date
Should be Empty:

2024-2025 AFTER SCHOOL ACADEMY REGISTRATION FORM

PARTICIPANT INFORMATION

OTHER INFORMATION

CITY OF FREMONT RELEASE AGREEMENT FOR ALL PARTICIPANTS

AFTER SCHOOL ACADEMY 2024/25

INTERNET AND ONLINE RESOURCE ACCESS

Photo/Likeness Release Form

ASA-PARENT AGREEMENT

ASA-STUDENT AGREEMENT