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STUDENT INFORMATION
Please clearly print the following information
Student's Name: _____________________________________________________
First Middle Last
Student's Address: _____________________________________________________
____________________________________________________
Telephone: ______________________ DOB: _________________________
School: ________________________________________
Grade: ____________ Age: _______________ Sex: ________ M ________F
SKILL / INTEREST
Please list any skill/interest of the student
1. _________________________________2. ________________________________
PARENT/ GUARDIAN INFORMATION
Parent / Guardian Name: ________________________________Relationship: ____________
Address: ____________________________________________________________
___________________________________________________________
Home Phone: ______________________ Work Phone: ____________________
Email: __________________________________ Cell Phone: ________________________
EMERGENCY CONTACT (Other than Parent)
Emergency Contact's Name: ____________________________Relationship: ______________
Home Phone: ____________________________ Cell/Work Phone: ______________________
MEDICAL CONDITIONS
Does your child have any medical conditions that might affect his/her participation in the After-school program (i.e. Asthma, sports related injuries, allergies, ADD, etc)?
If yes, please explain: __________________________________________________________________
CONSENT
I/we parent(s) or guardian(s) of ________________________________________(student's name) give permission to my child to participate in Raising Hope After-school programs. I shall indemnify, hold harmless, and defend Raising Hope, Inc., The Center" (Venue of Program), and their officers and employees, except in cases of willful negligence or misconduct on their part, against any and all claims, action, or suits brought for damages or alleged damages, and from all liability, loss, and expense, including reasonable legal expenses, resulting from any injury to person or property or from loss of life sustained by my child while my child is a participant at the Raising Hope After-school programs, Raising Hope, Inc. and "The Center." I/we understand that as a Parent/Guardian, I/we will be contacted if medical attention is required for my/our child while in the program. If I/we cannot be reached, I/we hereby authorize an administrator or staff of the After-school program, Raising Hope, Inc. or "The Center" to arrange for treatment as necessary.
I/we irrevocably consent to and authorize the use and reproduction by the After-school program and Raising Hope, Inc of any and all photographs, recordings, videotapes, and/or other reproductions of likenesses of the child's person or characteristics ("reproduction") for any purpose whatsoever, without compensation to the child. All reproductions shall constitute the property of Raising Hope, Inc. solely and completely.
Further, I/we assign and release all rights to said reproductions and authorize Raising Hope, Inc. or others authorized by them, to exhibit, broadcast, and/or distribute or otherwise further reproduce said reproductions in whole or in part over or in any medium whatsoever, including, without implied limitation, newsletters, radio, newspapers, closed circuit television, film, cable, and television, with or without compensation in perpetuity. I/we also release, discharge, and agree to hold harmless the producers or any persons or entities acting under their permission or authority from any liability arising from the use of said reproductions.
Parent/Guardian Name: _______________________________________________
Signature: _____________________________________Date: _____________________________
RETURN COMPLETED FORM TO: RAISING HOPE, INC
66 BURNETT STREET
PROVIDENCE, RI 02907
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