Grace F3 Afterschool Camp

- When school is in session
- Located at “Literacy Now” Belmont Apt 197B
- Pre-Kindergarten—5th Grade

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Section 1

Student Information

Let's learn about your student!

What is your student's name, age, and date of birth? *

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Male

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Female

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Is your student attending bilingual classes? *

Yes

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No

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Is your student in special education? *

Yes

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No

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Does your student have any allergies? *

Yes

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No

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Does your student have any medical conditions? *

Yes

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No

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Parent/Guardian Information

Let's learn about you as the parent/guardian.

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What is your name and relationship to the student? *

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How many are in your household? *

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Are you a single parent? *

Yes

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No

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What is your email address? *

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What is your primary contact phone number? *

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What is your preferred method of contact? *

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What is your preferred language? *

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Media Release

I hereby grant permission for Friends of Westchase to photograph, interview or videotape my child. It is my understanding that this photograph/interview/taping or portions thereof may be used for public view (newspaper articles, printed promotional materials, slideshows, television programs or on our website).
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I agree to allow my child to participate in programs run by Friends of Westchase without financial remuneration. I understand that by signing below, I release any photographer, interviewer, or Friends of Westchase volunteer or staff person from any future claims, as well as from any liability arising from the use of said interview, photograph, video or printed material.

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Inputting your name above acknowledges a legally binding agreement.

Today's date *

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Proceed

Section 4

Consent to Release

Please review and sign one of the following:

Walk Home

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Pick Up

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Permission to Walk Home

I give permission for my child to walk home after the Grace F3 Afterschool Camp. I understand that Friends of Westchase will not be held responsible for any accidents that may occur when my child leaves the program premises. I understand that my child will only be allowed to walk home with my written consent. By signing this form, I release Friends of Westchase, its staff, and volunteers from all liabilities.

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Permission for Pick Up

I give permission for my child to be picked up after the Grace F3 Program. I understand that Friends of Westchase will not be held responsible for any accidents that may occur when my child leaves the program premises. I understand that my child will be picked up, only with my written consent. By signing this form, I release Friends of Westchase, its staff, and volunteers from all liabilities.

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Sign

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Inputting your name above acknowledges a legally binding agreement.

Today's date *

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