After School Registration Form - Finding Me Academy Global
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1COMPLETE
COMPLETE ONE FORM PER CHILD
AFTER SCHOOL
AFTER SCHOOL REGISTRATION FORM
Participant’s Name
Age
_____________________________________________________
____________________________________________________________________
___________
Address
Date of birth
____________________________________________________________
_________________________________
_______________________
City
State
Zip
_______________________________
___________
___________________
___________________
Parent/Legal Guardian’s Name
_________________________________________________________________________
_________________________________________________________________________
Home Phone
Cell Phone
Work Phone
______________________
____________________
____________________
____________________
Email Address
_________________________________________________________
_____________________________________________________________________________________________
IN CASE OF EMERGENCY
Contact # 1
Contact # 2
Name
Name
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Address
Address
__________________________________________________
______
__________________________________________________
__________________________________________________
Home #
Home #
___________________________________________________
__________________________________________________
___________________________________________________
___________________________________________________
Cell #
Work #
Cell #
Work #
______________________
____________________
_______
_____________________
_____________________
_____________________
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Participant’s Allergies:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Participant’s Medical Conditions:
____________________________________________________________________________________________
____________________________________________________________________________________________
________________________________________________________________________________________________
Name of Participant’s Physician
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Physician’s Telephone
_______________________________________________________________
_____________________________________________________________________________________________________________
______________________________________________
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WAIVER OF
OF LIABILITY RELEASE FORM
I am aware of the nature of this activity and I hereby assume
assume responsibility for _________________________________________________
________________________________________________
(Participant’s Name)
to participate and to be photographed for publicity purposes
purposes. I will not hold Finding Me Academy
Global and/or its employees responsible in the case of
of accident or injury as a result of this
participation. I understand that this completed form must
must be in the possession of Finding Me Academy Global prior to participation in this program.
prior to participation in this program.
Parent/Legal Guardian Signature __________________________________________________________________
__________________________________________________________________ Date ________________________________
________________________
Amount Paid _________________ ( ) M.O. ( ) Cash ( ) Check # ______________
______________ Receipt $ ______________ Received by _______________ Date ______________
______________
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Parent category: Life