Before and After Program Registration Form - The Municipality of the District of St. Mary's

Participant Information

Please Note: if your child is staying after school for the Before and After Care Program, you must write a note in your child’s agenda for every day your child will be staying for the program. Teachers/staff must know when your child is NOT getting on their regular bus.

Child Name(*)

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Date of Birth(*)

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Grade(*)

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Age(*)

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Home Phone(*)

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Home Address(*)

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Physician Name(*)

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Physician Contact Number(*)

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Medical Conditions:

Please list any medical conditions or allergies that BAP staff should be aware of, and any medications that may be required during the program. Please enter N/A if there are no medical issues for child. If your child requires medication administration, there will be an additional medication administration form required.

Medical Conditions(*)

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Parent/Guardian Contact Information:

First Parent/Guardian Name(*)

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First Parent/Guardian Work Phone

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First Parent/Guardian Cell/Home Phone(*)

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Second Parent/Guardian Name

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Second Parent/Guardian Work Phone

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First Parent/Guardian Email(*)

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Second Parent/Guardian Email Address

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Emergency Contact Information

Emergency Contact Name(*)

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Relationship to Child(*)

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Emergency Contact Work Phone

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Emergency Contact Cell or Home Phone(*)

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Media Release

As part of our efforts to promote the Before and After Program and the activities and achievements of students, personal student identifying information, including name, grade, school, video/voice/audio recordings, images (photos) of students and/or student work will also be shared with the Regional Centre for Education for use in their print, online and social media (Twitter, Facebook, etc.) promotional platforms.

(*)

I give permissionI do not give permission Invalid Input

Child Pick Up Information

Please List all parties that have permission to pick up child at program (please include parent(s) and any other individuals that will be picked up your child)(*)

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Parent/Guardian Signature

I hereby give permission to the above mentioned youth to participate in the Municipality of the District of St. Mary’s Before and After Care Program located at St. Mary’s Education Centre Academy.

Parent/Guardian Signature(*)

Sign Above

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Signature Date(*)

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Permission to Leave Property

Please check each location you give permission for your child to walk to while at the Before and After Program(*)

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Waiver

Please Read before signing:

I, the parent/guardian of the above listed participant hereby give my approval for that child to participate in any and all activities pertaining to Before and After Care Program. I, THE UNDERSIGNED, RELEASE AND AGREE TO INDEMNIFY AND HOLD HARMLESS THE MUNICIPALITY OF THE DISTRICT OF ST. MARY’S, ITS STAFF, VOLUNTEERS, AND SPONSORS FROM ALL CLAIMS ARISING FROM ANY LOSS OR INJURY SUFFERED BY THE ABOVE NAMED PARTICIPANT WHILE INVOLVED IN THE BEFORE AND AFTER CARE PROGRAM.

Please indicate name of parent guardian signing waiver(*)

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I, the above listed, have read and understand the above waiver.

Waiver signature(*)

Sign Above

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Today's Date

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Security check(*)

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Before and After Program Registration

Participant Information

Medical Conditions:

Parent/Guardian Contact Information:

Emergency Contact Information

Media Release

Child Pick Up Information

Parent/Guardian Signature

Permission to Leave Property

Waiver

Residents