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After-School Fun Centers

Registration/General Release Form 2013-2014


* = Required Field

Please use only letters and numbers, commas, periods or apostrophes in the form fields.
Other special characters will not be allowed.



*Participant first name:
*Participant last name:
*Current grade:
*Birth date:



Parent 1's first name:
Parent 1's last name:
Day phone:
Evening phone:
Address:
City:
Zip:
*E-Mail address:



Parent 2's first name:
Parent 2's last name:
Day phone:
Evening phone:
Address:
City:
Zip:
E-Mail address:

Program Dates

August 8, 2013 through June 4, 2014.

*PLEASE NOTE: This program is offered only when school is in session. It is not held when schools are on intersession breaks, holidays or on staff development days.

Students must be registered with payment prior to participation. A $5 late registration fee will be charged to your account if student is not paid on or before the Monday of the current session by 12 pm. A weekly rate is charged and you may register in advance by using the following options:
  • Register and pay for fun center online at www.cityofpalmdale.org. A current e-mail address must be provided in order to register online.
  • Register at the recreation and culture office, 38260 10th Street East, Palmdale.
  • Phone in your registration and pay with credit card by calling the recreation and culture office at 661/267-5611.

*Program Sites (select site where your child will attend):
Cottonwood Elementary School
Esperanza Elementary School
Rancho Vista Elementary School

A sign-in and sign-out sheet will be used for the program. We recommend a parent or legal guardian, over the age of 18, sign all participants out of the program. This is important to ensure your child's safety. If you choose to alter this recommended procedure, please indicate by checking which release procedure you prefer:
My child may leave at any time by signing himself/herself in and out.
My child may leave at the designated time of p.m. by signing himself/herself out.
Please hold my child until picked up by a parent or one of those listed below.

EMERGENCY CONTACT & AUTHORIZED TO RELEASE

Please name the persons allowed to sign for your child's release from the program. Also include home and work numbers in the event of an emergency; we can contact you or someone you have designated. Please list people who are able to pick the child up in the event of an emergency. Please note: Staff will attempt to reach parents first before trying emergency contacts.
IMPORTANT: If staff is unable to reach parents or emergency contacts by 6:30 pm the Sheriff's Department will be notified. The child will be picked up by a deputy and kept in their care until a guardian arrives.
*Emergency contact #1:
*Relationship:
*Phone:
*Emergency contact #2:
*Relationship:
*Phone:
*Emergency contact #3:
*Relationship:
*Phone:



MEDICAL INFORMATION: Does participant have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness, hyperactivity or any other significant medical conditions that would limit or prevent their participation in this program?

Yes     No

If yes, please state problems below and list restrictions:


Known Allergies*: (please list)

* Should program participant be susceptible to a food allergy, be advised that program staff do not monitor consumption of food items.

City of Palmdale staff CANNOT be responsible for administering any medication.

RELEASE, WAIVER, AND ASSUMPTION OF RISK

   I, the undersigned, am fully aware and understand the potential risk involved with my, or my child's participation in this physical activity. Dangers could include, but are not limited to cuts, bruises, broken bones and other debilitating or permanent physical and emotional injury, damage to personal property, or death. (INITIALS)
   I acknowledge that I voluntarily participate, or allow my child to participate, in this program. I hereby agree to assume all risk of injury, damage to persons and property, or death, and to hold the City of Palmdale, its officers, agents, volunteers or employees harmless from any liability for any injuries, or claim for damage, damage to goods, or death that may arise in connection with participation in this program. This Release, Waiver and Assumption of Risk also pertains to any actions of negligence by the City of Palmdale, its officers, agents, volunteers, or employees (excepting only the sole negligence or willful misconduct of the City) which may have caused or contributed to the injury, damage, or death. This Release, Waiver, and Assumption of Risk shall be binding upon my heirs and dependents as well as myself. I allow my child to participate freely and voluntarily in this activity and expressly assume all the risk of this program. (INITIALS)
   I hereby give permission to the City of Palmdale Recreation and Culture Department to use my or my child's photographs as they see fit in their seasonal recreational brochure. I understand the photographs belong to the City and I will not receive payment of any kind. (INITIALS)
   In the event of illness or injury, the Palmdale Recreation and Culture Department is authorized to seek medical treatment and care for the above-named participant. (INITIALS)
   I understand that my child will not be under any supervision walking to and from the site. Also, children who arrive early will not be under any supervision until they are signed in. Children staying late will be supervised, however, a late fee will be charged. Once the program concludes for the day parents are given a 5 minute grace period to pick up their child. After the 5 minutes grace period there is a $1.00 per child charge for every 1 minute following. A $5 late registration fee will be charged to your account if student is not paid on or before the Monday of the current session by 12 pm. Late fees will be added to your account at www.cityofpalmdale.org. (INITIALS)
   In the absence of a signature, fees paid and participation in the program and all its related activities shall constitute acceptance of the conditions set forth in this release. (INITIALS)

*Name of Participant and/or Parent/Guardian
(Must be over 18 years of age or older)



*Date


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