After School Academy Application

Emergency Contact Form
Does the student have medical insurance?
Medical Insurance Name
Medical Insurance #
Doctor's name
Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Does the student have dental insurance?
Dental Insurance Name
Dental Insurance #
Dentist's Name
Dentist's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 1 Name

First NameLast Name
Emergency Contact 1 Home Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 1 Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Name

First NameLast Name
Emergency Contact 2 Home Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Can someone pick up the student other than the parent/guardian?
Who can pick up the student(s) other than the parent/guardian?

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
(For Summer Academy or After School Academy Only) Does your child have permission to walk home alone?
Please sign
Date

MonthDayYear
Release of Liability

I agree that I, my successors, assignees, heirs, insurers, agents, guardians, and legal representatives waive and release any rights, actions, or causes of action against Sacred Heart, its officers, directors, and employees, the suppliers of any materials used, and any of Sacred Heart’s volunteers, or recipients of Sacred Heart services, (collectively, the “Released Parties”) for injury, death, loss of use, damages arising out of or resulting from the acts or omissions of any person or entity or my activities as a customer. This includes, without limitation, negligence of any of the Released Parties, whether active or passive, sole or comparative, or other negligence, however caused, arising from or relating to Sacred Heart or my participation with Sacred Heart in any way. I understand that Sacred Heart would not allow me and my child(ren) to participate as a student (s) without my agreeing to this waiver and release and the other terms of this agreement.
Print Parent/Guardian's Name
Parent/Guardian Signature
Date

MonthDayYear
List Students in program

Field Trip/Park Permission Form
Student(s)
I give permission for my child to attend all the field trips and walks to local parks. I understand that my child will be traveling on either public transportation, private transportation, or walking to these field trips/parks. I also give permission for my child to walk to outdoor playgrounds and participate in sports activities at these playgrounds.

In case of an accident, I release Sacred Heart Community Service from all liability.
Print Parent/Guardian's Name
Parent/Guardian Signature
Date

MonthDayYear

Photographic/Media Model Release
Student(s)
I consent to the unrestricted use of any photographs, recordings, interviews, videotapes, film, or similar visual or auditory recordings of me, my dependents, and/or children in any medium, including the internet (hereafter “The Content”), by Sacred Heart Community Service (SHCS), or any person authorized by SHCS, created in connection with my participation with SHCS. I agree that I am not entitled to and will not receive any compensation for use of this Content or works derived from it and that SHCS is the sole owner of rights in the Content.
Print Parent/Guardian's Name
Parent/Guardian Signature
Date

MonthDayYear
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