Register your household now!

If you submit your application and you are NOT in our system, your application will be returned to you and your child will NOT be enrolled until we have received your household Registration!

Health Insurance: I understand that if emergency medical care is necessary and I cannot be reached, I authorize First State C.A.A. to act in my behalf in granting permission for my child to receive emergency medical treatment. Parents are responsible for all expenses incurred as the result of medical treatment.

• I understand that any/all information obtained is prohibited from re-disclosure.
• The requested information is needed to assist in evaluation, monitoring, reporting and program implementation.

Please enter your initials in each box below indicating that you understand and agree to the following:

Time Limit & Rights to Revoke Authorization: I understand that this authorization is valid for one year from the date of its signing or until the child is no longer enrolled in the program. I may revoke this authorization at any time by notifying the providing organization in writing, however, by revoking this consent my child will be dis-enrolled from the program. I also understand that by signing this release below, I am also authorizing First State Community Action Agency, Inc. to verbally consult/communicate with the above organization until enrollment is no longer in effect.

For your child’s safety, please list individuals that have permission to pick-up your child from the program. Our staff will not allow your child to leave the premises with an individual unless they are indicated on the list. Individuals must be 18 years old to sign-out your child. Additionally, your child will only be released to people that have been identified and who have appropriate picture identification.

*Please notify staff if you have a court ordered document preventing an individual from picking up your child.

I agree and do hereby release from liability and to indemnify and hold harmless First State Community Action Agency and any of its employees or agents representing or related to First State Community Action Agency as regards to the First State Community Action Agency Afterschool/Summer Programs. This release is for any and all liability for personal injuries (including death) and property losses or damage occasioned by, or in connection with any activity or accommodations for First State Community Action Agency, Afterschool/Summer Programs. I, the undersigned, further agree to abide by all the rules and regulations promulgated by First State Community Action Agency.

Health Insurance: I understand that if emergency medical care is necessary and I cannot be reached, I authorize First State C.A.A. to act in my behalf in granting permission for my child to receive emergency medical treatment. Parents are responsible for all expenses incurred as the result of medical treatment.

• I understand that any/all information obtained is prohibited from re-disclosure.
• The requested information is needed to assist in evaluation, monitoring, reporting and program implementation.

Time Limit & Rights to Revoke Authorization: I understand that this authorization is valid for one year from the date of its signing or until the child is no longer enrolled in the program. I may revoke this authorization at any time by notifying the providing organization in writing, however, by revoking this consent my child will be dis-enrolled from the program. I also understand that by signing this release below, I am also authorizing First State Community Action Agency, Inc. to verbally consult/communicate with the above organization until enrollment is no longer in effect.

For your child’s safety, please list individuals that have permission to pick-up your child from the program. Our staff will not allow your child to leave the premises with an individual unless they are indicated on the list. Individuals must be 18 years old to sign-out your child. Additionally, your child will only be released to people that have been identified and who have appropriate picture identification.

*Please notify staff if you have a court ordered document preventing an individual from picking up your child.

I agree and do hereby release from liability and to indemnify and hold harmless First State Community Action Agency and any of its employees or agents representing or related to First State Community Action Agency as regards to the First State Community Action Agency Afterschool/Summer Programs. This release is for any and all liability for personal injuries (including death) and property losses or damage occasioned by, or in connection with any activity or accommodations for First State Community Action Agency, Afterschool/Summer Programs. I, the undersigned, further agree to abide by all the rules and regulations promulgated by First State Community Action Agency.

Health Insurance:  I understand that if emergency medical care is necessary and I cannot be reached, I authorize First State C.A.A. to act in my behalf in granting permission for my child to receive emergency medical treatment. Parents are responsible for all expenses incurred as the result of medical treatment.

• I understand that any/all information obtained is prohibited from re-disclosure.
• The requested information is needed to assist in evaluation, monitoring, reporting and program implementation.

Time Limit & Rights to Revoke Authorization: I understand that this authorization is valid for one year from the date of its signing or until the child is no longer enrolled in the program. I may revoke this authorization at any time by notifying the providing organization in writing, however, by revoking this consent my child will be dis-enrolled from the program. I also understand that by signing this release below, I am also authorizing First State Community Action Agency, Inc. to verbally consult/communicate with the above organization until enrollment is no longer in effect.

For your child’s safety, please list individuals that have permission to pick-up your child from the program. Our staff will not allow your child to leave the premises with an individual unless they are indicated on the list. Individuals must be 18 years old to sign-out your child. Additionally, your child will only be released to people that have been identified and who have appropriate picture identification.

*Please notify staff if you have a court ordered document preventing an individual from picking up your child.

I agree and do hereby release from liability and to indemnify and hold harmless First State Community Action Agency and any of its employees or agents representing or related to First State Community Action Agency as regards to the First State Community Action Agency Afterschool/Summer Programs. This release is for any and all liability for personal injuries (including death) and property losses or damage occasioned by, or in connection with any activity or accommodations for First State Community Action Agency, Afterschool/Summer Programs. I, the undersigned, further agree to abide by all the rules and regulations promulgated by First State Community Action Agency.

Health Insurance: I understand that if emergency medical care is necessary and I cannot be reached, I authorize First State C.A.A. to act in my behalf in granting permission for my child to receive emergency medical treatment. Parents are responsible for all expenses incurred as the result of medical treatment.

• I understand that any/all information obtained is prohibited from re-disclosure.
• The requested information is needed to assist in evaluation, monitoring, reporting and program implementation.

Time Limit & Rights to Revoke Authorization: I understand that this authorization is valid for one year from the date of its signing or until the child is no longer enrolled in the program. I may revoke this authorization at any time by notifying the providing organization in writing, however, by revoking this consent my child will be dis-enrolled from the program. I also understand that by signing this release below, I am also authorizing First State Community Action Agency, Inc. to verbally consult/communicate with the above organization until enrollment is no longer in effect.

For your child’s safety, please list individuals that have permission to pick-up your child from the program. Our staff will not allow your child to leave the premises with an individual unless they are indicated on the list. Individuals must be 18 years old to sign-out your child. Additionally, your child will only be released to people that have been identified and who have appropriate picture identification.

*Please notify staff if you have a court ordered document preventing an individual from picking up your child.

I agree and do hereby release from liability and to indemnify and hold harmless First State Community Action Agency and any of its employees or agents representing or related to First State Community Action Agency as regards to the First State Community Action Agency Afterschool/Summer Programs. This release is for any and all liability for personal injuries (including death) and property losses or damage occasioned by, or in connection with any activity or accommodations for First State Community Action Agency, Afterschool/Summer Programs. I, the undersigned, further agree to abide by all the rules and regulations promulgated by First State Community Action Agency.

Health Insurance: I understand that if emergency medical care is necessary and I cannot be reached, I authorize First State C.A.A. to act in my behalf in granting permission for my child to receive emergency medical treatment. Parents are responsible for all expenses incurred as the result of medical treatment.

• I understand that any/all information obtained is prohibited from re-disclosure.
• The requested information is needed to assist in evaluation, monitoring, reporting and program implementation.

Time Limit & Rights to Revoke Authorization: I understand that this authorization is valid for one year from the date of its signing or until the child is no longer enrolled in the program. I may revoke this authorization at any time by notifying the providing organization in writing, however, by revoking this consent my child will be dis-enrolled from the program. I also understand that by signing this release below, I am also authorizing First State Community Action Agency, Inc. to verbally consult/communicate with the above organization until enrollment is no longer in effect.

For your child’s safety, please list individuals that have permission to pick-up your child from the program. Our staff will not allow your child to leave the premises with an individual unless they are indicated on the list. Individuals must be 18 years old to sign-out your child. Additionally, your child will only be released to people that have been identified and who have appropriate picture identification.

*Please notify staff if you have a court ordered document preventing an individual from picking up your child.

The agree and do hereby release from liability and indemnify and hold harmless First State Community Action Agency and any of its employees or agents representing or related to First State Community Action Agency as regards to the First State Community Action Agency Afterschool/Summer Programs. This release is for any and all liability for personal injuries (including death) and property losses or damage occasioned by, or in connection with any activity or accommodations for First State Community Action Agency, Afterschool/Summer Programs. The undersigned further agrees to abide by all the rules and regulations promulgated by First State Community Action Agency.