General After School Program Registration - Waiver Form printable pdf download

Alhuda

248 East Mountain St. , Worcester MA 01606

Tel: 508- 854-4700

Fax: 508-854-4711

Academy

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: ___________________________________________________________________________________________

Street

City

State

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)

General After School Program Registration - Waiver Form