Epiphany After-School Club Registration Form 2019-2020 School Year (NO FEE) Student’s Name First Last Student’s Grade Level for 2019-20Student’s Grade Level for 2019-20KGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Enroll Student inEvery Day for the entire school yearDrop In OnlyParent’s / Guardian’s First Last Parent’s / Guardian’s Phone NumberParent’s / Guardian’s Email Emergency Contact Name First Last Relationship to StudentEmergency Contact Email Emergency Contact Phone NumberAllergiesYesNoPlease List Allergies Below:Medications Currently TakingPhysicianPhysician Phone NumberMedical Insurance CarrierMedical Insurance Policy NumberAuthorized Persons to pick up StudentConsent – Please type your name below. By typing your name, you agree to the terms as follows: First Last CONSENT FORM To be Completed by Parent/Guardian By submitting your name below, you are permitting your child to participate in the Epiphany After-School Club. As the parent/guardian, you remain fully responsible for any legal recourse that may result from any personal actions taken by the named student. Parents must supply all medication needed during Epiphany After-School Club. Medications (with instructions) should be given to the supervisor in charge. By submitting your name below, you acknowledge consent for participation of your child at the Epiphany After-School Club. You give permission for your child, in case of emergency, to be taken to a physician or hospital by school/camp personnel. You understand that every effort will be made to contact you in the event of an emergency. If you cannot be reached, however, you hereby give permission to the physician selected by the designated supervisor to hospitalize and secure proper treatment (including surgery) for you child. It is understood that the resulting expenses will be the responsibility of the parent/guardian and not the school or Bear City Play Date, LLC. You recognize that the registration fee is non-refundable.