Emergency Information and Consent Form

Student's Name

First Name

Last Name

Student's Grade

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Phone

(###)

###

####

Parent/Guardian Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Email

Name(s)/Phone number(s) of person(s) authorized to pick up child

In addition to the Parent(s)/Guardian(s) listed above

Name and Phone of two (2) Emergency Contacts

Different than the Parent(s)/Guardian(s) listed above

List any allergies (N/A if not applicable)

List any relevant medical, physical, social/emotional information about your child you’d like staff to be aware of

Parent/Guardian name acknowledging below Waiver & Consent

First Name

Last Name

Waiver and Consent

I am the parent or legal guardian of the child registering in the before or after school activity designated above. I hereby agree to follow all registration requirements and have read and agree to the After School Pick-up/Drop-off Policy document. I understand that there are certain risks of injury in this before or after school activity and I willing to assume these risks on behalf of my child. I hereby certify that my child is fully capable of participating in this activity. I agree, in taking advantage of this before or after school activity, to release and hold harmless the Chesterbrook Elementary School PTA, including its officers, agents, members, and volunteers; Chesterbrook Elementary School, including its officers, agents, and employees; and any person or persons providing the before or after school activity from any and all claims, demands, suits, costs (including attorneys’ fees and litigation costs) and charges, in connection with or arising out the activity, including but not limited to bodily harm or injury to my child and/or negligence, action, or inaction of the released parties above. In the event of injury, accident, and/or illness of my child, I hereby authorize my child to be transported to an emergency medical facility and authorize the provision of any and all medical treatment which may be deemed advisable. I also hereby assume financial responsibility for any such transport, treatment and/or related expenses. I have read this release and further agree that no oral representations, statements, or inducement apart from the foregoing waiver and consent have been made.

Chesterbrook Elementary PTA