After-School Program Registration

Recreation Center

Child's Name, Age

School

Grade

Home Phone Number

Cell Phone Number

Cell Phone Number 2

Emergency Contact (other than parents)

Relationship to Child

Phone Number

Please List Who Is Authorized To Pick Up Your Child

Authorized Person One

Relationship to Child

Phone Number

Authorized Person Two (optional)

Relationship to Child

Phone Number

Authorized Person Three (optional)

Relationship to Child

Phone Number

Is your child under a doctor's care or taking medication?

Yes

Please explain:

By signing below I am agreeing to the following:

Medical Treatment: As a parent or legal guardian of the above-named participant, I hereby give my consent for emergency medical care prescribed by a licensed Doctor of Medicine, Doctor of Dentistry or Emergency Medical Technician/Paramedic. This care may be given under whatever conditions are necessary to preserve life, limb or well-being of my dependent.

Behavior: As a parent or legal guardian of the above-named participant, I understand that my dependent may be dismissed from the program for disciplinary reasons at any time without recourse or refund.

Damages: In consideration of you accepting my child’s entry, I hereby, for myself, my child, my heirs, executors and administrators, waiver and release all rights and claims for damages I or my child may have against the City of Huntsville and its representatives, successors and assigns for any and all injuries suffered by myself or my child at any activity sponsored by the City of Huntsville Parks and Recreation Department.

Photo Release: I hereby authorize the City of Huntsville, Alabama to publish and use my child’s name and/or my child’s likeness (“Likeness”) for the promotion publicity, advertising, or other manner or media by the City of Huntsville (the “City”) Department of Parks and Recreation or any other representative authorized to act on behalf of the City. A full copy of the waiver can be obtained at the recreation center’s front desk.

Fees: $20 per student per week, $10 for each additional child. Payment may be made weekly. First payment must be received before start date.

Code of Conduct:

No weapons allowed on the property
No profanity or fighting is allowed (seek staff for intervention)
No using or possession of tobacco products, vapes, or alcoholic beverages
No vandalism of property
No running in the hallways
No sagging pants
No hats or bandannas inside the facility
No food, drinks, or candy in gyms or computer labs
Do not leave the facility unless you are with staff or your parent/guardian

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.