Questions?ContactJenny Allen (203) 921-6327 or email@example.com PLEASE COMPLETE AND SIGN THE BACK OF THIS FORM
NMS FALL 2016 HOMEWORK CLUB REGISTRATION FORM, PAGE 2
DOESYOURCHILDREQUIREANYACCOMODATIONSTOPARTICIPATE? YES NO
Ifyoucheckedyes, please identify the nature of the accommodation(s) requested (i.e. medical, language, behavioral):
Parents with a child requiring any accommodation for special needs please note:
To help your child have a positive experience in HOMEWORK CLUB, you are encouraged to discuss with your child's class teacher or other school staff.
I give permission for the staff of the Greenwich Public Schools to share the information with the BEFORES &
AFTERS class instructor and coordinators as to an appropriate accommodation for my child
me to discuss my child's participation and class selection.
---------------------------------------------------------------------------------------------- MEDICALWAIVERANDCONSENT: Please be advised that the schoolnurseisonlyondutyfrom8:30amto3:15pm. The nurse' s hours do not cover the times when BEFORES & AFTERS classes are being held. It is the responsibility of the instructors to handle any medical
emergency. A first aid kit is available for use by the instructors. Instructorswillcall911for anymedicalemergency. Ifyou haveachildwithspecialmedicalneeds(severefoodallergies,asthma,etc.),itisyourresponsibilitytoconveythis informationtotheCoordinator, since this information is considered confidential and therefore cannot be passed on by the school nurse or staff. This is not a change in policy; it is simply an effort to keep you informed.
I have read and understand the above notice regarding the handling of medical emergencies during North Mianus School
BEFORES & AFTERS program.
ToAllParticipatingBEFORES & AFTERSFamilies:
I, the undersigned parent and/or legal guardian of the above named child, and enrolled student of North Mianus School, do hereby give my permission and approval for his/her participation in the program(s) listed above and, therefore, assume all the risks and hazards incidental to such participation, including but not limited to the risk of serious harm or injury as a consequence of undetected physical conditions on any playing field or surface, negligence of any instructor, or intentional conduct of any other participant. I understand that any sports activity poses inherent risks to healthy individuals and further certify that my son/daughter is in good physical condition with no known factors which would preclude him/her from participating in vigorous physical activity and hereby consent to his/her participation. On behalf of my child and family, I freely and voluntarily agree to release, indemnify, and hold harmless the Greenwich Board of Education, The School, the School's PTA, the Greenwich PTA Council, its administrators, contractors, parent volunteers, and instructors from any and all liabilities arising from an incident due to my child's involvement and participation in the School' s PTA sponsored BEFORES & AFTERS
Furthermore, I have read and agree with the NMS AFTERS Policies and Procedures as stated in Program Guidelines.