• Robstown ISD21st Century ACE Afterschool Program 2026-2027

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  • DATE OF BIRTH:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • GENDER:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • PLACE AN "X" ON YOUR PREFERRED WAY TO BE CONTACTED:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • PLACE AN "X" ON YOUR PREFERRED WAY TO BE CONTACTED:*
  • HOW DOES YOUR CHILD NORMALLY GET HOME?*

  • Who has permission to pick your child up at the end of the day, besides yourself?

  • I understand that if my child is supposed to be picked up and is not by the end of programming, the afterschool staff may call Robstown PD. After three late pick-ups, my child may be excused from the program.*
  • Format: (000) 000-0000.

  • AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT: In case my child has an accident or sudden illness, and in the event I cannot be reached by phone, I hereby authorize a representative of RISD to refer my child to the physician named above or seek appropriate medical care. RISD cannot be held responsible for any cost incurred.

  • DATE:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • CONTACT IN CASE OF EMERGENCY AND PARENTS CANNOT BE REACHED:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • PLEASE READ RELEASES

  • * I give permission to the program to transport my child in agency vans and/or staff-operated vehicles to and from our after-school site on special field trips (separately authorized by parent or guardian).

  • * I understand and agree that neither the program nor its employees and volunteers are responsible or legally liable for any personal property losses or for any bodily injuries incurred and suffered by the child on any program property or in connection with any program activities.

  • * I give the afterschool staff permission to access school records (grades, attendance, behavior, etc.) about my child to better serve his/her needs.

  • * I give the afterschool staff permission to release my child's student ID # to Robstown ISD's program providers for the purpose of assessing program effectiveness. Only group data (i.e. information regarding grades, attendance, behavior, etc. for all the students in the program) will be examined, no data specifically connected to your student will be identified.

  • * I understand that the records and information released under this consent will be kept confidential to the extent permitted by law and will be used for the purpose indicated.

  • * I understand that if my child is absent from the afterschool program, I will receive a phone call notifying me of the absence unless I have already given notice that my child is not going to attend the program.

  • * I understand that if I have any questions about these releases, I can ask my program coordinator.

  • I HAVE READ THE ABOVE STATEMENTS AND I AGREE TO THE ABOVE STATEMENTS.

  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • I will allow my child to be photographed and/or videotaped while engaged in program activities and for those images to be used for publicity and/or recruitment purposes.

  • PLEASE READ THE BEHAVIOR MANAGEMENT POLICY

    Your child is expected to behave appropriately at all times and follow the rules of the 21st Century ACE Program & RISD.

  • ALL INFORMATION IS COMPLETELY CONFIDENTIAL

  • I am the parent or legal guardian of the minor named above and have legal authority to execute this consent and release.

  • DATE:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: