Student Information

Parent/Guardian Information

Student Pick-up Information (Pick-up Only)

Please list at-least 2-3 authorized persons with phone numbers who you give permission to pick-up your children from the program.

Emergency Contact Information

In the event of an emergency, please list two people we may contact who know your child and can take full responsibility should you not be available.

After School Program (To be filled out by staff)

Parent/Guardian Consent for Photographs and Internet Use

Parent/Guardian Consent to Participate in the After School Program

Children are required to maintain a minimum monthly attendance rate of 90%. Children are required to attend at least three program hours daily, unless a written early dismissal policy is in place. A late fee of $30.00 is due for late pick up past closing time, which is 5:30 PM. In the event of excessive tardiness (i.e. 3 late pick-ups), participant may not be allowed continued access to the program.

In case of an emergency injury or illness, I authorize the Program to call the paramedics. As legal guardian of the above listed student, a minor, I authorize the Rise Up & Walk After-School representative or designee to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis, treatment, and/or hospital care to be rendered upon the advice of any licensed physician and/or dentist.
The program is not responsible for personal items. I have read and understand the above and handbook.