Student's Last Name:
Student's First Name:
Parent / Guardian Last Name:
Parent / Guardian First Name:
Date of Birth:
Grade: Pre-KKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6
Home Phone Number:
Cell Phone Number:
Parent / Guardian Work Phone Number:
Emergency Phone Number:
Physician's Phone Number:
Does your child take medication?
Type of Medication:
Does your child have allergies?
Type of Allergies:
Does your child have dietary needs?
Specify the needs:
Any additional needs that the staff should be aware of?
Emergency Pick-Up Information (If you cannot be reached)
Please list people your child may be released to:
Please list people your child MAY NOT be released to:
I give permission for my child, , to participate in all activities that are part of the Erving After School Academy. I give permission for the After School Academy staff to attend to any emergency that may occur during the session and seek medical attention, if necessary. I understand that if I cannot be reached, the staff will contact one of the emergency names I have listed.
Parent / Guardian Electronic Signature: Date:
By checking this box, you acknowledge this Electronic Signature is your acceptance and agreement as if actually signed by you in writing for this Permission Form.