After School Care
By 51 Services, LLC
918-321-0012
Registration and Information
Child's Name
*
Age
*
Child's Birthday
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade Entering
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
Format: (000) 000-0000.
Guardian's Name
*
First Name
Last Name
Phone
*
Format: (000) 000-0000.
Guardian's Name
First Name
Last Name
Phone
Format: (000) 000-0000.
Email Address(s):
*
example@example.com
Parent's Address (If Different from Above)
Others Living in Family Group:
Name
Age
Relationship to Child
Health and Safety
Child's Physician
*
Phone
Format: (000) 000-0000.
Health Problems or Concerns
*
Medications and Dosage
*
Allergies
*
Adverse Reactions
The following people may pick up my child or be notified in case of emergency if we cannot be reached
Rows
Name
Phone
Relationship to Child
1
2
The following people may not pick up my child:
I wish to enroll my child in the ASC Program. I Agree to comply with the rules and regulations regarding fees, withdrawals, and procedures
*
I Agree
I have read and understood that there will be a late fee of $1.00 per minute after 5:35 pm.
*
I Agree
I have agreed to give ASC a 2 week advance notice of withdrawal before the 1st of the following month, or that month's tuition is due.
*
I Agree
Parent's Signature
*
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
After School Care by 5L Services Forms
Revised July 2026
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After School Care
By 51 Services, LLC
Emergency Care Authorization
I, We, the undersigned, parent(s) or legal guardian(s) of the minor listed below.
Minor's Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Minor's Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Minor's Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do hereby authorize any X-ray examination, anesthetic, dental, medical, or surgical diagnosis or treatment by any physician or dentist licensed by the state of Oklahoma and hospital service that may be rendered to said minor under the general, specific, or special consent of After School Care Inc, the temporary custodian of the minor. Whether such diagnosis by the state of Oklahoma. I, We, authorize the physician or dentist to call in any necessary consultants at his/her discretion.
It is understood that this consent is given in advance of any specific diagnosis or treatment being required but is given to encourage those people who have temporary custody of the minor, and said physician or dentist, to exercise his/her best judgment as to the requirements for such diagnosis or medical or dental or surgical treatment.
This consent shall remain effective until 6:00 P.M on the 30
th
of May 2027. Unless sooner revoked in writing, delivered to said physician or dentist or said people entrusted with the custody, care, and control of the said minor child(ren).
Legal Guardian Signature
*
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
After School Care by 5L Services Forms
Revised July 2026
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After School Care
By 51 Services, LLC
ASSUMPTION OF RISK / WAIVER OF LIABILITY / INDEMNIFICATION AGREEMENT
In consideration of being allowed to participate on behalf of the After School Care program offered by 5L Services, LLC. and related events and activities, the undersigned acknowledges, appreciates, and agrees that:
1. Participation includes possible exposure to and illness from infectious diseases including but not limited to MRSA, Influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe and any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and,
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS to 5L Services, LLC and their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors, of premises used to conduct the event ("RELEASEES"), WITH RESPECT TO ANY AND ALL ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULL UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IF FREELY AND VOLUNTARILY WITHOUT AN INDUCEMENT.
FOR PARTICIPANT OF MINORITY AGE (UNDER AGE 18 AT THE TIME OF REGISTRATION)
This is to certify that I, as parent/guardian, with legal responsibility for this participant, have read and explained the provisions in this waiver/release to my child/ward including the risks of presence and participation and his/her personal responsibilities for adhering to the rules and regulations for protection against communicable diseases. Furthermore, my child/ward understands and accepts these risks and responsibilities. I for myself, my spouse, my child/ward do consent and agree to his/her release provided above for all the Releasees and myself, my spouse, and child/ward do release and agree to indemnify and hold harmless the Releasees for any and all liabilities incident to my minor child's/ward's presence or participation in these activities as provided above, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent provided by law.
Child's Name:
*
Today's Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent's Name:
*
Signature:
*
After School Care by 5L Services Forms
Revised July 2026
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