2024-2025 After School Program Application

School*

Program*

AM (Before School)PM (After School)

District

Full Name*

First, Middle Initial, Last

Date of Birth*

Date

Grade*

Student ID#

Street Address*

Apt #

City*

Zip Code*

Parent/Guardian 1 Name*

Please include First Name, Middle Initial, Last Name

Phone Number (Main)*

Phone Number (Other)*

Parent/Guardian 1 Email*

email@example.com

Parent/Guardian 2 Name

Please include First Name, Middle Initial, Last Name

Phone Number (Main)

Phone Number (Other)

Parent/Guardian 2 Email

email@example.com

Child is living with:*

Mother/Parent/Guardian 1Father/Parent/Guardian 2BothOther

I give consent for my child to participate in activities / surveys design to evaluate the effectiveness of the Arc after school program.*

YesNo

Initial*

Contact 1*

Please enter their full name.

Relationship*

Phone Number*

Address (Street, City, Zip)*

Contact 2*

Please enter their full name.

Relationship*

Phone Number*

Address (Street, City, Zip)*

Contact 3

Please enter their full name.

Relationship

Phone Number

Address (Street, City, Zip)

Pupil Designation

Homeless YouthFoster Care

I/We authorize the Beyond the Bell Before/After-School Program (BASP) to contact, and if necessary, release my child to any of the above individuals listed as an Emergency Contact/Release Information. The above listed individuals must be 18 years or older.
I/We give my permission for my child to be filmed or photographed. I understand that all film or photos are the sole property of the BASP, and may be used
I/We hereby consent to the disclosure of personally identifiable information from my child’s education records under the Family Educational Rights and Privacy Act and allow for the Los Angeles Unified School District to disclose such information only to the extent and for the duration necessary for my child to participate in BASP programs.
The After School Education and Safety (ASES) Program Act of 2002, enacted by initiative statute, establishes the After School Education and Safety Program to serve pupils in kindergarten and grades 1 to 9, inclusive, at participating public elementary, middle, junior high, and charter schools. The act gives priority enrollment in after school programs and before school programs to pupils in middle school or junior high school who attend daily. Pupils who are identified by the program as homeless youth or as being in foster care will be given first priority. Parents/guardians may indicate this information below:

Does your child have any physical, emotional, and/or learning difficulties? If so, please specify.

Does your child have any food allergies? If so, please specify.

RELEASE OF LIABILITY and ASSUMPTION OF RISK This document affects your legal rights. Read and understand it before initialing or signing it.

DUTY OF PARTICIPANTS: Some recreational activities conducted by Good Sports Plus Ltd. doing businessas arc (hereinafter, “arc”) may be hazardous to participants. All participants have a duty to act as a reasonablyprudent person when engaging in the recreational activities offered by arc. I hereby covenant and agree not to: a) act in any way which shall interfere with the running or operation of rock climbing or any other activity when such activities conform to the rules and regulations of the State of California. b) use any of arc equipment or facilities or services if I do not have the ability to use such facilities, equipment, or services safely without instructions until I have requested and received sufficient instruction to permit safe usage. c) Engagein any harmful conduct or willfully or negligently engage in any type of conduct which contributes to or causes to cause injury to any person. d) To embark in any self-initiated activity without first informing arc of my intentions and receiving permission from arc to engage in such self-initiated activity.

ACKNOWLEDGMENT AND ACCEPTANCE OF RISK: I understand and acknowledge that the activities in which my child(ren) will voluntarily engage bear certain known and unanticipated risks that could result in injury, death, illness or disease, physical or mental, or damage to, my child(ren) property, or to spectators or other third-parties. I accept and assume all responsibility and risk for injury, death, illness, or disease, or damage to my child(ren) and/or my property. My child(ren)’s participation in this activity is purely voluntary; no one is forcing participation, and I elect to have my child(ren) participate in spite of all known and unknown risks.

PICTURES / VIDEO: All pictures/video taken in connection with the arc program are the sole and exclusive property of arc and may be used in any promotional materials.

RELEASE: In consideration of the services and/or property provided, I, for myself and any minor children for which I am the parent, legal guardian, or otherwise responsible, any heirs, personal representatives, or assigns, do hereby release arc, its principals, directors, officers, agents, employees, and volunteers from any and all liability and waive any cause of action or complaint for any damage whatsoever arising from any cause whatsoever (except that which is gross negligence). I further agree to reimburse arc for all attorney’s fees and costs should Ibring legal action against arc and lose.

ENTIRE AGREEMENT: I understand that this is the entire Agreement between myself and arc, its agents or employees, and that it cannot be modified or changed in any way by the representatives or statementsof any employees of arc or by me. My signature below indicates that I have read this entire document and understand it completely and agree to be bound by its terms.

Parent/Guardian's Name*

Signature*

Date*

Date

Parent/Guardian's Name

Signature

Date

2024-2025 After School Enrollment - LAUSD

STUDENT INFORMATION

PARENT(S)/GUARDIAN(S)

EMERGENCY CONTACT/RELEASE INFORMATION

ACKNOWLEDGEMENT