After-school Application 23-24 Please fill out the form completely. Student Information First Name Last Name Date of Birth Gender MaleFemaleNon-Binary Grade Level Primary Address Apt/Unit City State Zip Code Home Phone Emergency Contact Info & Authorized Adults For Pick Up 1st Parent/Legal Guardian Name Address Primary Phone Secondary Phone 2nd Parent/Legal Guardian Name Address Primary Phone Secondary Phone Additional Emergency Contact & Authorized Adults For Pick Up (must be at least 18 years old) Contact #1 Name Relation Primary Phone Secondary Phone Contact #2 Name Relation Primary Phone Secondary Phone My Child May Not Be Picked Up By Individual #1 Name Relation Individual #2 Name Relation Student Medical & Health Information/History Name of Doctor Insurance Carrier/Policy # Carrier Phone Medical Info/History RCP Parent Release of Liability - (read before submitting) Considering that my child/ward is being allowed to participate in the RCP After-school Program, its related events and activities, I, the undersigned, acknowledge, appreciate, and agree that: The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, FOR MYSELF, SPOUSE AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERS, AN ASSUME FULL RESPONSIBILITY FOR MY CHILD’S PARTICIPATION: AND, I willingly agree to comply with the program’s stated and customary terms and conditions for my child’s participation. If, however, I observe any unusual significant concern in my child’s readiness for participation and/or in the program itself, I will remove my child from participation and bring such to the attention of the nearest official; immediately: and I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY AND HOLD HARMLESS RCP, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertiser, and, if applicable, owners, and lessors of premises used for the activity (“RELEASES”), WITH RESPECT TO ANY ANS ALL INJURY, DISABILITY, DEATH or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. I understand my child must participate a minimum of 12 hours a week. Consents (select Yes or No) A. I authorize my child to be released to individuals listed on this registration form at the close of each program day and in case of emergencies. I understand that my child must be signed out by a parent/guardian or approved adult who is 18 years or older and are listed on this registration form. YesNo B. I understand that in case of emergencies, RCP will make every effort to contact parents/legal guardians before any treatment is given. In the event that we cannot be contacted, I hereby authorize the physician or hospital selected by RCP to hospitalize, secure treatment for and to order injection, anesthesia, or surgery for my child. It is further understood that I will assume full responsibility for any such treatment, including the payment of all costs and transportation and will hold RCP Directors and program staff, harmless therefrom. YesNo C. I authorize my child to be photographed or video-taped by RCP Staff or the news media for purposes relating to the after-school program. YesNo D. I give RCP staff consent to have access to my child’s current and past records such as grades/report cards, test scores, Academic and behavioral data, demographic information, etc. YesNo E. I authorize my child to participate in evaluation activities such surveys/questionnaires and focus groups that will be administered while in the RCP after-school program. YesNo F. I agree with the terms, guidelines, and conditions of the program’s Code of Conduct. YesNo G. I authorize my child to sign him or herself out to walk home at the end of the program day. YesNo H. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. YesNo Submit Application I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. Parent/Guardian Submitting Application Name Email Please leave this field empty.