UCS Aftercare Registration
2019-2020
Student Name
*
First Name
Last Name
Student birth date
*
-
Month
-
Day
Year
Date
School your child attends
*
Homeroom teacher
*
Room #
*
Grade
*
Free or reduced lunch?
*
Yes
No
Contact Information
Parent/guardian name
*
First Name
Last Name
Relationship to child
*
Annual household income
*
$0-$10,000
$10,001-$20,000
$20,001-$30,000
$30,001-$40,000
$40,001-$50,000
$50,001-$60,000
$60,001 or greater
Home address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work phone
*
-
Area Code
Phone Number
Cell phone
*
-
Area Code
Phone Number
Home Phone
*
-
Area Code
Phone Number
Work/school
*
Work/school phone
*
-
Area Code
Phone Number
Where can you be reached while your child is at the program?
*
Email address
*
example@example.com
Emergency Contact 1
Name
*
First Name
Last Name
Home Number
*
-
Area Code
Phone Number
Cell Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact 2
Name
*
First Name
Last Name
Home Number
*
-
Area Code
Phone Number
Cell Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Permission to Transport and Administer First Aid
Preferred Hospital/Clinic
*
Preferred Dentist
*
I give UCS After Care permission to administer First Aid if needed and to have my child transported to the medical facilities listed above or to the nearest available source of assistance.
*
Name of physician
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Name of dentist
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Medical/hospitalization coverage
*
Please list any allergies, physical/psychological concerns, or any special circumstances or issues at home, etc. that we should know about:
*
I understand that Saint Ignatius High School, the Arrupe Neighborhood Partnership Program, Urban Community School, or its designees will assume no responsibility for accidents, for medical, dental, or other expenses incurred as a result of any course of instruction given to the participant by the staff. I hereby authorize Saint Ignatius/Arrupe Staff or its designees to act for me in any emergency requiring medical attention. I authorize Saint Ignatius/Arrupe and Urban Community School Staff or designees to send my child to a medical facility for diagnosis or treatment if necessary.
*
Parent Handbook Endorsement
Signature
*
Photo Release
In order to use pictures for general communications and public relations purposes, it is necessary that we request your permission to do so. This authorization allows for Arrupe Neighborhood Partnership Program (ANPP) and Saint Ignatius High School (SIHS) to use your child’s photo in ANPP/SIHS publications and promotional materials, including newsletters, pamphlets, our web page (www.ignatius.edu/arrupe), or any other news media. No compensation is given for the use of photographs. I hereby authorize Arrupe Neighborhood Partnership Program and Saint Ignatius High School to use photos of my child in Arrupe Neighborhood Partnership, Saint Ignatius High School related publications and promotional materials as mentioned above. Please check out our Facebook page, “Arrupe Neighborhood Partnership” for updated photos of what is occurring at the Arrupe Afterschool Programs.
*
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