32n Out-of-School Time After School Enrollment Form 2025-2026

In the event of a medical emergency, what is the Hospital Preferred for Medical Treatment:

Medical Conditions/Allergies/Disabilities or Special Instructions ("check" conditions that apply or check "none"):

Food allergies?

Allergic to Bees?

YESNO

Allergic to Bees?

YesNo

Other:

If medication is to be distributed during the program, I understand that a medication authorization form must be on file with the program leadership Initials and it is my responsibility to make sure the leadership has the authorized medication to be administered in a timely manner Initials .

Please describe any Special Instructions/Information that may be useful for staff to know:

****Additional Contacts can be used for transporting of my student if I am not available (initials)****

EMERGENCY CONTACT 1

Phone:

Format: (000) 000-0000.

Add'l Phone:

Format: (000) 000-0000.

Relationship to Student:

EMERGENCY CONTACT 2

Phone:

Format: (000) 000-0000.

Add'l Phone:

Format: (000) 000-0000.

Relationship to Student:

EMERGENCY CONTACT 3

Phone:

Format: (000) 000-0000.

Add'l Phone:

Format: (000) 000-0000.

Relationship to Student:

****PLEASE READ THE STATEMENT BELOW AND CHECK THE BOX NEXT TO EACH STATEMENT

Rows	YES	No
Emergency Medical Treatment: I give permission to the program staff (licensed by the State of Michigan) to secure emergency medical and/or surgical treatment for the above.
Family Handbook: I have received a copy of the Family Handbook. I agree to the program’s policies
Playground Equipment Recognition. The program utilizes the playground equipment available at our sites. I understand the equipment students use may not comply with licensing standards.
Immunization Records. My Child’s immunization records are up-to-date. The immunization record or appropriate waiver is on file with the school. My child is in good health with activity restrictions noted.
Contact Information. I agree to contact the program leadership at my site if my contact information changes.
Field Trip. I hereby give my permission for my student to attend field trips. I understand that information will be provided prior to every field trip. I agree to accept all medical responsibility in case of emergency due to accident or illness.
Topical Application Waiver. I give permission to the program staff to provide my child with insect repellant, sunscreen, and Neosporin wound cleanser when appropriate. I understand that specific product information is available upon my request from the program leadership team.
Program Enrollment. I understand that enrollment in this program is voluntary. In order to assure that each student makes the desired progress for academic success, I understand regular attendance is expected.

1

YESNo

1

2

YESNo

2

3

YESNo

3

4

YESNo

4

5

YESNo

5

6

YESNo

6

7

YESNo

7

8

YESNo

8

By signing my student up, I authorize this program to collect and use data about my child for the purposes of program development, safety, and improving educational outcomes. I understand that this data will be kept confidential, stored securely, and used by authorized personnel within the organization, and shared with Michigan Department of Lifelong Education, Advancement, and Potential (MiLEAP) 32n OST Grants Program and state evaluation partners.

Signature of Parent/Guardian:

Printed Name of Parent/Guardian:

Date:

"This before school, afterschool, and summer program is made possible by a grant awarded by MiLEAP under 32n OST Grants Program."

32n Out-of-School Time After School Enrollment Form 2025-2026

Parent 1/Legal Guardian

Parent 2/Legal Guardian