Registration form september 19- december 20

NMS FALL 2016

HOMEWORK CLUB REGISTRATION FORM

September 19– December 20

You must read and sign all sections of this form (FRONT and BACK)
Please use one registration form for each child. Additional forms are available on the Oops table near the front office and online.

Make checks payable to NMS PTA and write your child's first and last name on the memo line of the check. Drop off completed forms, in a sealed labeled envelope at the Oops table.

ENCLOSE THIS FORM ALONG WITH PAYMENT IN A LABELED & SEALED ENVELOPE
Child's Name: _ ^{Grade/Teacher:}

Parent/Guardian Name: ^{Daytime Phone#: _ E-mail Address} Evening Phone#:

Emergency Contact Name (other than parent listed above):
Relationship: _ ^Phone#:

_{AFTERS DISMISSAL INSTRUCTIONS- PLEASE CHECK ONE:}

	I will pick up my child from NMS and will adhere to crosswalks and traffic patterns in parking lot.
	^My^child^will^walk^home^from^school
	My child is registered with NMS Childcare- Dismiss to cafeteria

_{DAY SELECTIONS:}

Class Name	Day	Fee	Check#
Homework Club (no classes 10/3)	Monday	$195
Homework Club (no classes 11/8 & 12/6)	Tuesday	$195

Incomplete forms will not be processed!

_{Questions? Contact Jenny Allen [phone] or [e-mail]}
PLEASE COMPLETE AND SIGN THE BACK OF THIS FORM
NMS FALL 2016 HOMEWORK CLUB REGISTRATION FORM, PAGE 2
DOES YOUR CHILD REQUIRE ANY ACCOMODATIONS TO PARTICIPATE? YES NO
If you checked yes, 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

I would like a staff member of the Greenwich Public Schools or BEFORES & AFTERS Coordinator to contact

me to discuss my child's participation and class selection.

^{----------------------------------------------------------------------------------------------}
MEDICAL WAIVER AND CONSENT:
Please be advised that the school nurse is only on duty from 8:30am to 3:15pm. 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. Instructors will call 911 for any medical emergency. If you have a child with special medical needs (severe food allergies, asthma, etc.), it is your responsibility to convey this information to the Coordinator, 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.

IF YOUR CHILD HAS SPECIAL MEDICAL CONCERNS CHECK HERE: Explanation:
I have read and understand the above notice regarding the handling of medical emergencies during North Mianus School

BEFORES & AFTERS program.

Parent/Guardian Signature: Date (REQUIRED)

To All Participating BEFORES & AFTERS Families:
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


_{program(s) noted above.}

Furthermore, I have read and agree with the NMS AFTERS Policies and Procedures as stated in Program Guidelines.

Parent/Guardian Signature: Date (REQUIRED)