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Before+After School Program Enrollment

Participant and Parent Information
First Name
Last Name
Country
Address Line 1
City
State
Postal Code
Is the student eligible for free or reduced lunch?
No file selected

First Name
Last Name
Would you be willing to be a career day speaker at EYFO

First Name
Last Name
Would you be willing to be a career day speaker at EYFO

Emergency Contact information and Authorization Pick- up Information

Person/s to be contacted in the case of an emergency/authorized pick up other than parents or guardians.

EMERGENCY 1ST CONTACT
First Name
Last Name
EMERGENCY 2ND CONTACT
First Name
Last Name
EMERGENCY 3RD CONTACT
First Name
Last Name

I Receive Subsidy from the Following

Medical History and Authorization Information
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I hereby authorize and consent to the administration of any and all medical dental and surgical examination or operations and treatment or all other related care, including emergency transportation.

I understand that Empowering Youth and Families, its volunteers or facilities and their officers, employees assume no financial obligator or liability in case of my child’s accident or illness. I assume full financial responsibility for emergency treatment for my child. EYFO carries no additional liability coverage for illness or accident for your child.


General Authorization and Information
My Child experiences the following
Learning Disability - Does your child have a current Individualized Education Learning Plan (IEP)?

Fieldtrips and Outings
My child has permission to participate to attend fieldtrips including but not limited to visits to the parks, beach shopping, movies, museums, water parks, neighborhood walks or other fieldtrips as scheduled by means or walking, bus, van or metro

Release of Publication
My child may be photographed for EYFOs publication

Release and Indemnity Agreement

The foregoing information is complete and true to the best of my knowledge. I also confirm the authorizations and consent detailed within this document. I understand that should my child act in a manner that is unsafe for him/her self he/she may be excluded from the program. I hereby release, discharge and covenant not to sue EYFO, its employees, volunteers, officers, agents and the facilities used for all liability to me or my child or my child’s personal representatives, assigned heirs and next of kin from any and all claims, demands, losses or damages on account of any injury or damage to property caused or arising from my child’s participation in the program.