C.A.R.E.

CURTIS AFTER SCHOOL RECERATION & ENRICHMENT PROGRAM

PERMISSION FORM

PLEASE COMPLETE ONE FORM FOR EACH CHILD

NAME OF STUDENT__________________________________________

GRADE_________ TEACHER__________________ ROOM #__________

PARENT / GUARDIAN_______________________ PHONE#___________

EMERGENCY CONTACT:

NAME_____________ PHONE#_

NAME_____________________________ PHONE#_________________

DOCTOR___________________________ PHONE#________________

INSURANCE & ID #_________________________________________

PLEASE LIST ANY ALLERGIES / MEDICAL CONDITIONS THAT WE SHOULD BE AWARE OF ______________________________________________________________________
____________________________________________________________________________________________________________________________________________

THE FOLLOWING PEOPLE ARE AUTHORIZED TO PICK UP:

NAME____________________RELATION_______________PHONE#___________

Note: For the safety of our students, we require a form of picture I.D. when picking up a child. All children MUST be picked up by 5:30 p.m. Excessive late pick up will result in a fee of $1.00 per minute. All tuition payments MUST be paid weekly to avoid legal action, if we need to seek unpaid balances you will held responsible for ANY cost accrued. This is a permission slip for program attendance; if we schedule an out of building field trip a separate notice will go out. By signing this form you as the parent/guardian agree to all stated terms & conditions of the program.

PARENT/ GUARDIAN SIGNATURE_____________________________

DATE______________________

The Pawtucket School Dept. has a ZERO TOLERANCE POLICY that includes after school programs. I understand that my child will be asked to leave the program if he/she does not follow program rules.

If any emergency medical procedures or treatments are required during the program, I consent leader in charge taking, arranging for or consenting to the procedures or treatment in his, her or their discretion.

Initial__________

The Pawtucket School Dept. does not provide students insurance coverage for bodily injury during regular school activities including field trips.

I release and waive, and further agree to indemnify, hold harmless or reimburse the school committee, the individual members, agents, employees and representatives thereof, as well as program supervisors from against, any claim which I, any other parent / guardian, any sibling, the student, or any other person, firm or corporation may have or claim to have, known or unknown, directly or indirectly for any losses, damages or injuries arising out of, during, or in connection with the student’s participation in the trip or rendering of emergency medical procedures or treatment, if any.

To showcase our program we may take photos of the children during an activity to use in our publications.

No child WILL ever be identified unless otherwise noted in a separate release form that will require your signature.

Parent / Guardian Signature________________________________________

Address_________________________________________________________

_______________________________________________________________

Date_____________________

CURTIS AFTER SCHOOL REC & ENRICHMENT PROGRAM

FLORA S. CURTIS ELEMENTARY SCHOOL, 582 BENEFIT ST. PAWTUCKET, R.I. 02861

PHONE 401-729-6252 / FAX 401-721-2100