After School Application Form

Primary Insurance Company Policy No. Subscriber's Name Subscribers Relationship

Physician Name Phone No.
Address City

I do hereby consent to any medical care determined by a physician to be necessary for the welfare of my child(ren) in the event of a medical emergency while said child(ren) is under the care of Feed the Hungry Project and Louella Thompson Child Enrichment Center staff, and I am not reasonably available by telephone to give consent.

Yes or No

I do NOT hereby consent to any medical carefor my child(ren) determined by a physician or health care provider in theevent of a medical I emergency

Yes or No

I. Waiver and Assumption of Risk

a. I attest that my child is physically fit and sufficiently prepared for this program/event. I understand that my child’s participation in this program/event is voluntary. I further understand that serious accidents could occur during the Enrichment After School Program Summer Camp and that participants, including my child, could sustain personal injuries. Knowing these risks, and in consideration of the acceptance of the application for my child’s participation in the above referenced program/activity I hereby agree to the following:

b. I assume the risk of personal injury and property damage, and waive, release and discharge the Feed the Hungry Project, its council, officials and employees, and agents (“Feed The Hungry Project and or Louella Thompson Child Enrichment Center Program”) for any and all claims for damages for personal injury or personal property damage which I my children and our heirs, assigns, executors, or administrators may have or may accrue on my and my child’s behalf as a result of the release of my child to any person named on this form, except for injury or damage caused by the sole negligence or willful misconduct of the Feed the Hungry Project: and I agree to accept and abide by the rules and regulations set by the Feed the Hungry Project, sponsors and promoters.

II. Field Trips

a. The Enrichment Center Summer Camp Program will take field trips away from this facility/park. This trip may include the students having to be transported. Entrance fees will be covered for most events by the Enrichment Center Program. Any additional purchase (snacks, food, souvenirs, cost) will be covered by the parent/guardian. This notice is to make you aware of this portion of our program.

III. Photo/Tape/Audio Records

a. The program has my permission to photograph or to audio/video tape activities that include my child for purposes of program promotion.

IV. Transportation

a. The program will not be responsible for picking up or dropping off any children. Parents or Guardians are responsible for getting their kids to and from Smith Park.

I have read this waiver, understand its implications, and agree to its terms and conditions.

Signature of parent

After School Application Form

Insurance Information