AfterSchoolForm

After-School Program Registration

* Indicates required field

Child Name *

First

Last

Age *

Grade in Fall *

Sex *

School *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Parent/Guardian Name *

Relationship *

Phone Number *

Second Parent/Guardian Contact *

Email *

Relationship *

Phone Number *

Email *

Alternate Contact #1 *

Relationship *

Phone Number *

Alternate Contact #2 *

Relationship *

Phone Number *

Does your child require transportation from school? (If yes, please contact the school to complete a bussing permission slip) *

Is you child allowed to walk home alone from the program? *

Who is allowed to pick up your child? *

Who else is allowed to pick up your child? *

In the "additional information" box below, please list any medical conditions, allergies, food allergies, or other physical or mental limitations the HCC staff needs to know to better serve your child. Please contact the HCC at 814-643-4241 if you would like to share IEP, 504, or behavior management plans with the HCC staff.

Additional Information: *

Consent for Participation

I the parent/ guardian of the registrant, a minor, agree that the registrant and I will abide by the rules/ guidelines of the HCC it’s affiliated organizations and sponsors. I recognize the possibility of physical injury or illness from exposure to any bacteria, fungus, virus, unknown contagious diseases or COVID-19 associated with the HCC program. I further recognize the possibility of physical injury associated with this program and in consideration for the HCC, accepting the registrant for its programs and activities, I hereby release, discharge and or otherwise indemnify the HCC, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of facilities utilized for the program against any claims by or on behalf of the registrant as a result of the registrant’s participation in the program and or being transported to or from the same, which transportation I here-by authorize. Further permission must be granted by the HCC for the registrant without insurance coverage to participate.

Signature / Name *

Date *

Consent for Minor Medical Treatment

As a parent or legal guardian of the above participant, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb, or well-being of my dependent.

Signature / Name *

Date *

Medical Insurance *

Doctors Name *

Phone *

(Participation will not be denied based on whether or not participant is insured)

Photo/Video Consent

I/We grant permission for my child to have his/her photo/video taken and published on the HCC Programs public internet site or any other type of media.

Select One *

Communication Preferences

Thee HCC would like to better understand how participants currently hear about our programs and events, and also find out if there are better ways to communicate with our community.

How did you hear about the After-School program? *

How would you prefer to learn about HCC programs and events? (website, email, newspaper, Facebook, other ideas) *

After-School Program Policies and Rules

I have read and understand the After School Program Policies posted on the Huntingdon Community Center website and I have reviewed the rules and regulations for participation with my child.

Signature/Name *

Date *

Submit