General After School Program Registration - Waiver Form


248 East Mountain St. , Worcester MA 01606
Tel: 508- 854-4700
Fax: 508-854-4711
P.O. Box 4040 T/S, Shrewsbury, MA 01545
General After School Program Registration & Waiver Form
One Form per Student
CLUB / PROGRAM: ____________________________________________________________________________
Student Name: ___________________________________________________________Grade: _________________
Address: ___________________________________________________________________________________________
Zip Code
Home Phone Number: _______________________________
Father’s Name: ___________________________ Phone Number: ________________________
Mother’s Name: __________________________ Phone Number: ________________________
Emergency Contact Name: ______________________________________________________
Work Phone: __________________________________________________________________
Home Phone: __________________________________________________________________
Cell Phone: ____________________________________________________________________
Pager/Other/Specify: ____________________________________________________________
Please list any allergies or medical conditions that Alhuda Academy should be aware of:
Liability Waiver:
I understand that participation in interscholastic and other voluntary after school
athletics includes risk of injury that may range in severity from minor to disabling to even death. Although
serious injuries are not common in supervised school athletic programs, it is impossible to eliminate the risk.
I/we understand that my child’s participation in Alhuda Academy’s after school programs is voluntary and
that my child and I/we are free to choose not to participate. I/we consent to my child’s participation in any of
the approved athletic activities checked above and to accompany any school team of which she/he is a
member on its local or out-of-town trips. I understand that Alhuda Academy, their employees, officers and
agents will not be liable for personal injuries and/or property damage as a result of my child’s participation in
such programs or activities.
Committed to Excellence in Education that Builds Better Citizens and Better Muslims
Alhuda Academy is accredited by the New England Association for Schools and Colleges (NEASC)


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