2024-2025 CLUB ED Registration

PARENT/LEGAL GUARDIAN INFORMATION
Primary Parent/Guardian #1 (Enrolling Child)
- Will receive all Club Ed emails (including billing)
- Sign up for Remind System alerts
- Will be the first person contaced in an Emergency
- Incident Notify
- Can Pick Up
Primary Parent/Guardian #1 (Enrolling Child)*

First NameLast Name
Primary Parent/Guardian #1 Relationship to Student*
Primary Parent/Guardian #1 Cell Phone Number*
Please enter a valid phone number.
Primary Parent/Guardian #1 Other Phone Number
Please enter a valid phone number.
Primary Parent/Guardian #1 Email*
example@example.com
Primary Parent/Guardian #2
- Will be the second person contaced in an Emergency
- Incident Notify
- Can Pick Up
- Must opt in to receive emails or remind invite
Primary Parent/Guardian #2

First NameLast Name
Primary Parent/Guardian #2 Relationship to Student*
Primary Parent/Guardian #2 Cell Phone Number*
Please enter a valid phone number.
Primary Parent/Guardian #2 Other Phone Number
Please enter a valid phone number.
Primary Parent/Guardian #2 Email
example@example.com
Does Parent/ Guardian #2 request to be signed up for Club Ed Emails/Remind alerts?

YesNo
ADDITIONAL EMERGENCY CONTACTS/CARE
My child may be released to the following people in case of an emergency or following emergency medical care. Below are two authorized individuals who may be called during program hours if both Primary contacts are not available. Please indicate below if they have permission to pick up.
Emergency Contact 1 -My child may be released to the following person in case of an emergency or following emergency medical care.*

First NameLast Name
Emergency Contact 1 Relationship to Student*
Emergency Contact 1 Cell Phone Number*
Please enter a valid phone number.
Emergency Contact 1 Additional Phone Number
Please enter a valid phone number.
Indicate below if Emergency Contact 1 (name above) has permission to Pick Up your Student?*

YesNo
Emergency Contact 2 - My child may be released to the following person in case of an emergency or following emergency medical care.

First NameLast Name
Emergency Contact 2 Relationship to Student*
Emergency Contact 2 Cell Phone Number*
Please enter a valid phone number.
Emergency Contact 2 Additional Phone Number
Please enter a valid phone number.
Indicate below if Emergency Contact 2 (name above) has permission to Pick Up your Student?*

YesNo
ADDITIONAL DESIGNATED PICK UPS

(not listed above)
Designated Pick Up 1 -My child may be released to the following person.

First NameLast Name
Pick Up 1 Relationship to Student*
Pick Up 1 Phone Number
Please enter a valid phone number.
Designated Pick Up 2 -My child may be released to the following person.

First NameLast Name
Pick Up 2 Relationship to Student*
Pick Up 2 Phone Number
Please enter a valid phone number.
Designated Pick Up 3 -My child may be released to the following person.

First NameLast Name
Pick Up 3 Relationship to Student*
Pick Up 3 Phone Number
Please enter a valid phone number.
**Children below 5th grade are NOT ALLOWED to walk home alone.**
I give my child permission to walk home alone from the afterschool program.

NoYes
If yes, specify time of release*

Hour Minutes

AM/PM Option
DO NOT RELEASE STUDENT TO Enter Full Name Relationship to Student .
DO NOT RELEASE STUDENT TO Enter Full Name Relationship to Student .
DO NOT RELEASE STUDENT TO Enter Full Name Relationship to Student .

MEDIA CONSENT/ TERMS AND CONDITIONS
Media Consent /Check One*

I give permission for my child to be photographed or otherwise recorded during after-school events and activities, and for any and all such photographs to be displayed by Jewish Family & Children's Services of Northern New Jersey, Inc. in any medium books, newsletters, web sites, etc, whether now or hereafter known or developed.I DO NOT give permission for my child to be photographed or otherwise recorded during after- school events and activities.
POLICIES AND PROCEDURE ACKNOWLEDGEMENT

I give my child permission to participate in Club Ed Afterschool Program for the 2024-2025 school year. I understand that this consent will be effective as of the date of my signature and will remain in effect as long as my child is enrolled in the afterschool program.

By signing below, I confirm that I have received, understood, and agree to comply with all policies and procedures regarding my child's enrollment in the 2024-2025 Club Ed Afterschool Program.

1. General Program Information

2. Department of Children and Families, OOL

3. Release of Children

4. Student Behavior Guidelines

5. Discipline Guidelines

6. Expulsion

7. Management of Communicable Diseases

8. Injury & Medical Emergency Notification

9. Waiver of Liability & Assumption of the Risks

10. Medication Administration

11. Photo/Video Disclosure

12. Social Media/ Technology

13. Screen/TV/Video Guidelines

14. Methods of Parental Communication/Notification
Review and download the 2024-2025 Club Ed Parents/Guardians Manual for Policies and Procedures below. This will be a helpful resource though out the year.
PARENTGUARDIAN SIGNATURE*

Clear
DATE*

MonthDayYear
Date
Should be Empty:

CLUB ED REGISTRATION FORM

PAYMENTS

PARENT/LEGAL GUARDIAN INFORMATION

Primary Parent/Guardian #1 (Enrolling Child)

Primary Parent/Guardian #2

ADDITIONAL EMERGENCY CONTACTS/CARE

ADDITIONAL DESIGNATED PICK UPS

Children below 5th grade are NOT ALLOWED to walk home alone.

MEDICAL/ HEALTH INFORMATION

MEDIA CONSENT/ TERMS AND CONDITIONS

POLICIES AND PROCEDURE ACKNOWLEDGEMENT

CLUB ED REGISTRATION FORM

PAYMENTS

PARENT/LEGAL GUARDIAN INFORMATION

Primary Parent/Guardian #1 (Enrolling Child)

Primary Parent/Guardian #2

ADDITIONAL EMERGENCY CONTACTS/CARE

ADDITIONAL DESIGNATED PICK UPS

**Children below 5th grade are NOT ALLOWED to walk home alone.**

MEDICAL/ HEALTH INFORMATION

MEDIA CONSENT/ TERMS AND CONDITIONS

POLICIES AND PROCEDURE ACKNOWLEDGEMENT

Children below 5th grade are NOT ALLOWED to walk home alone.