A+ 2024 Summer Program

2024 Summer Program

June 3-28
Summer Program Registration Form

2024-2025
Please complete each item. Choose N/A if item is not applicable.

Section I - Student & Family Information
Child's Name
Family/Guardian Name
Family Street Address
City
State
Zip
Cell Phone
School Child Attends
Date of Admission

MonthDayYear
Date
Please select 1, 2 or 3 to set order of phone number used to reach you:
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Section II - Authorization for Emergencies

List 3 Emergency Contacts Authorized To Take Child From The Program:
Name
Phone
Name
Phone
List Medical Contacts, In Case Of Emergency:
Physician
Dentist
Other
Phone
Phone
Phone
Sign Grant Permission To Provide First Aid & Transportation To Emergency Care Facilities:
Signature of Authorized Family Member/Guardian

Powered by Jotform SignClear
If you do not want your child transported to an emergency care facility or provided first aid, describe procedures to follow:
Please complete both pages of form

Section III - Child's Health Information
Child's Medical/Health Needs
Child's Allergies/Treatment
Child's Dietary Needs/Restrictions
Child's Medication/s: A Medication Form Must Be Completed For Each Medication Administered While In Program
Section V - Transportation/Activity Authorization

Complete To Allow Child To Leave Program For Specific Activities With Specific People
Destination/Activity
Departure Time
Authorized Person
Return Time
Departure Time Authorization Time Period:
Time Period
Authorized Person
Return Time
Departure Time Authorization Time Period:
Time Period
Authorized Person
Return Time
Date

MonthDayYear
Date
Signature of Authorized

Powered by Jotform SignClear
MEDIA / 'ELECTRONIC RELEASE FORM
Student's Name
Grade
A+ Arts Academy after school program may develop, participate in, or be the subject of media and/or electronic based internet presentations such as the A+ Arts Academy home page and events that highlight various educational activities that take place during the course of the school year. Theses presentations/ events will include but will not be limited to the following: Videotapes Computer=-generated presentations that may incorporate scanned photographs and video clips Computer-based productions transmitted via telecommunications Photographs Web pages designed at school These media-based presentations may be used in: Student recruitment presentations Faculty presentations The A+ Arts Academy home page Staff development activities

Public relations (i.e. newspaper articles, TV presentations, etc day of (parent/guardian) and A+ Arts Academy after school program. The parent/ guardian hereby represents that he/she is the legal guardian of (student) and has the right to sign this release granting A+ Arts Academy permission to use the student's name and/or voice, likeness and any or all of the audio or video footage in any of the A+ Arts Academy or media based productions for the above stated purpose.

This release is made and entered into this
Signature of Parent/Guardian Date Signed

Powered by Jotform SignClear
(parent/guardian decline consent granting A+ Arts Academy permission to use my child's name, voice, or likeness in any of the circumstances mentioned above.
Signature of Parent/Guardian Date Signed

Powered by Jotform SignClear
Should be Empty:

2024 Summer Program

Summer Program Registration Form

MEDIA / 'ELECTRONIC RELEASE FORM