Application

Student Information

Start Date: *

KidSpace Elementary *

Sandstone Elementary

Sunset Elementary

Hurricane Elementary

Free or Reduced Lunch *

Free

Reduced

Pay for Lunch

We anticipate students will be attending the program daily. Please specify any day(s) your student will regularly not be attending program due to other engagements (i.e.: sports/recreational activities, scouts, student council, etc).

Student Last Name *

Student First Name *

Grade *

Gender

M

F

Address *

Address

City

State/Province

Zip/Postal

Student Date of Birth *

Parent/Legal Guardian Contact Information

1st Guardian First Name *

1st Guardian Last Name *

1st Guardian Email *

Home Phone Number

Cell Phone Number

Work Phone Number

Authorized Alternative/Emergency Contact(s) for Program and Student Pick-up (PHOTO ID REQUIRED TO PICK UP STUDENT)

First Name *

Last Name *

Relationship to Student *

Phone Number *

Add Remove

Departure Options *

Agreements

Photo and Media Release

As the parent/legal guardian, I give the OST Program permission to use photographs/video taken during the program time for use in different media formats to communicate with the community and other stakeholders. Your initial will act as legal agreement.

Health Information and Treatment Consent *

Yes

No

Please check yes if there are any medical conditions that the after-school staff may encounter during the time they spend with us. If your child needs an alternate snack due to medical reasons, please send them with your child.

Please describe the medical condition(s) including the appropriate treatment.

Date *

Student OST Code of Conduct Agreement *

Student understands that any violation of the Code of Conduct may result in disciplinary action.

I hereby grant permission for my student to attend the OST Program. I am aware of the Community & Global Engagement Out of School Time Program Parent Handbook is available online and agree to the regulations and policies set forth therein. I understand that my student must abide by all rules as set forth in the Parent Handbook and as given by the program staff. I agree that if my student fails to follow the rules of the program that they may be asked to withdraw and their spot awarded to another student. I release the OST Program from any and all liability resulting from my student attending the OST Program. I understand that it is my responsibility for the transportation of my student and that late fees may apply if my student is not picked up on time. *

Typing your full name will be viewed as your electronic signature.

Out-of-School Time Program Registration Form

Student Information

Parent/Legal Guardian Contact Information

Authorized Alternative/Emergency Contact(s) for Program and Student Pick-up (PHOTO ID REQUIRED TO PICK UP STUDENT)

Agreements

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