UNIT 4 - Art Room After School for Grades 5 - 8
If you are registering multiple children, a separate form must be completed for each child
THURSDAYS 3:30 - 5:00 pm
April 3 - May 29
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 Name
*
First Name
Last Name
Parent Email
*
example@example.com
Parent Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent 2 Name
First Name
Last Name
Parent 2 Email
example@example.com
Alternative Phone
Format: (000) 000-0000.
Emergency Contact Information
Please list an adult other than the parent/guardian already provided. In the unlikely event of an emergency, we will contact the parent/guardian first, then if we cannot reach the parent/guardian, we will then reach out to the emergency contact.
Emergency Contact Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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 a parent/guardian cannot be reached?
*
Yes
No
Authorized Adults for Pick Up
Please list the first AND last names of additional adults that have authorization to pick up the student. *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 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, I have given my permission to have my child receive medical 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 photos or videos of your child for the purpose of promotion and increasing public awareness of our program?
*
Yes
No photos, please.
Submit
Should be Empty: