AGAPE

Out of School Time Program
Documents required to complete OST registration:
- Out of School Time Program Application
- Medical Release form
- Photo Release form
- Transportation Permission Slip and Liability Waiver
- Please provide separately:
  - Up to date immunization records
  - School progress report/report card
Questions? Please contact us:

info@agapehavenofabundance.org

(585) 434-0109

Registration Form is good for one year unless information changes.
After School Program
Child's Name
Address
Date of birth

MonthDayYear
Date
Social Security
Age
School
Current Grade
How were you referred?
Medical disclosure
(special needs/disability/allergies)
Returning Participant?
Medical release
Physician contact
Household size
18 and under
Siblings
Parent/Guardian Information
Name(s)
Relationship to Child
Primary Phone Number
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Emergency Contacts

*Please note all youth MUST have two
Emergency Contact 1

NameRelationship
Primary Phone
Please enter a valid phone number for emergency contact 1.
Secondary Phone
Please enter a valid phone number for emergency contact 1.
Emergency Contact 2

NameRelationship
Primary Phone
Please enter a valid phone number for emergency contact 2.
Secondary Phone
Please enter a valid phone number for emergency contact 2.
I hereby grant permission to have my child's photo taken. By signing this form I understand that photographic or video recordings may be electronically displayed via the internet or in the public educational setting and website. The release applies to photographs, video recordings, and audio.
Signature

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289 Driving Park Ave

Rochester, NY 14613

TRANSPORTATION SERVICES WAIVER AND RELEASE

Transportation Permission
I give permission for my child
to be transported in the vehicle I give permission for my child provided by Agape Haven of Abundance to attend afterschool activities and field trips. I recognize and acknowledge that Agape Haven of Abundance is neither a common carrier nor in the business of providing transportation services to the public. I further recognize and acknowledge that there are certain risks of physical injury to vehicle passengers, and I voluntarily agree to assume the full risk of any injuries, damages or loss, regardless of severity, that I may sustain as a result of participating in any and all activities connected with or associated with receiving transportation services, including, but not limited to, injuries, damages and loss arising out of negligent operation or supervision of the vehicle. I further agree to waive and relinquish all claims I may have (or accrue to me) against Agape Haven of Abundance, including its respective officials, agents, volunteers and employees. Transportation Services, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you might sustain as a result of said services, including but not limited to, vehicle operations and boarding and exiting the vehicle. I do hereby fully release and forever discharge the Party from any and all claims for injuries, damages or loss that I may have or which may accrue to me and arising out of, connected with, or in any way associated with said transportation services. I further agree that this agreement shall be governed by the laws of the State of New

I have read and fully understand the above waiver and release of all claims. If registering on-line or via fax, my on-line or facsimile signature shall substitute for and have the same legal effect as an original form signature.
Participant's Name Print
Participant or Guardian Signature

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Out of School Time Program

RELEASE OF MEDICAL AND/OR BEHAVIORAL HEALTH INFORMATION