Art Room After School for 1st-4th Graders : Unit 2
If you are registering multiple children, a separate form must be completed for each child
TUESDAYS 3:30 - 5:00 pm
December 3 - January 28
Astoria Middle School
1100 Klaskanine Ave, Astoria, OR
Student Information
Student Name
*
First Name
Last Name
Student Grade
*
What school does the student attend?
*
Parent Information
Parent 1 Name
*
First Name
Last Name
Parent 1 Email
*
example@example.com
Parent 1 Phone
*
Please enter a valid phone number.
Parent 2 Name
First Name
Last Name
Parent 2 Email
example@example.com
Parent 2 Phone
Please enter a valid phone number.
Emergency Contact Information
Emergency contacts are trusted adults that should be contacted in the event we cannot reach a parent/guardian. Please list a different adult in the fields below than yourself or parent/guardian 2.
Emergency Contact Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Email Address
example@example.com
Do you give this emergency contact authorization to act on your behalf in a medical emergency involving your child when parent/guardian 1 cannot be reached?
*
Yes
No
Authorized Adults for Pick Up
Please list the first AND last names of any other adults that have authorization to pick up the student from the program. *Adults can be added or removed from the list of authorized adults for pick up by emailing first AND last names to info@artroomastoria.org.
Medical Information
Does the student have any allergies or any health conditions that Art Room staff should be aware of?
I authorize staff of the Art Room after school program who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility to secure necessary medical treatment for my child.
*
Yes
Informed Consent/General Release
My child has permission to participate in the activities of the Art Room After School program at Astoria Middle School. I agree to release Astoria Visual Arts and its representatives from any claim for personal injury or damages resulting from my child’s participation in the activities associated with the program. I also understand that in the event of emergency or medical need, you have my permission to have my child receive medial treatment by the best means available. As the parent or legal guardian of the above named child, I am authorized to electronically sign this permission form.
*
I agree
Photo Consent & Release
Do you grant permission for our organization to use your child’s photo for the purpose of promotion and increasing public awareness of our program?
*
Yes, you may use photos for promotional purposes.
No photos, please.
Submit
Should be Empty: