REGISTRATION

FORM
2012-2013 school year

Students Name ___________________________________________ DOB ___________________ Grade ______

Students Address ______________________________________________________________________________


1. Name of Parent/Guardian _________________________________________

Home # ____________________ Work # ________________________ Cell # _______________________

Address (if different from above)____________________________________________________________

E-mail address_______________________________________________

2. Name of Parent/Guardian _________________________________________

Home # ____________________ Work # ________________________ Cell # _______________________

Address (if different from above)____________________________________________________________

E-mail address_______________________________________________

Child lives with ____________________________________________________

What information can you share to help us best meet your childs needs?________________________________

_____________________________________________________________________________________________

Does your child have an illness, allergy, health problem, or disability that we should be aware of? q Yes q No

If yes, please explain how the condition should be managed during ONWARD! program activities.
______________________________________________________________________________________________

______________________________________________________________________________________________

Does your child wear: q contact lenses q glasses?
For: q distance q close up or q both?

Are there any social, emotional, or behavioral issues we should be aware of?
______________________________________________________________________________________________

______________________________________________________________________________________________

Are there any limitations on your childs participation in ONWARD! program activities? q Yes q No
If yes, please explain_____________________________________________________________________________

______________________________________________________________________________________________

Is your child currently taking any medication? q Yes q No

If yes, please describe:___________________________________________________________________________

Does this medication need to be given during program time? q Yes* q No
* If yes, you must have a medical form on file with the school nurse. No
medications will be given unless the medical form has been completed. *

Do you have health insurance for your child? qYes qNo

If you do not have health insurance, call 1-800-250-VHAP for more information about obtaining low-cost insurance.


Medical Release
In the event that my child is injured or needs medical help I understand that hospital personnel will attempt to contact me before

administering
treatment to my child. If a parent cannot be reached, I hereby give permission for the person named below to
be called for authorization.

Emergency
Contact_______________________________________________________________________



Relationship_________________________
Home # _________________ Work # __________________

I authorize
ONWARD! staff to obtain emergency medical care for my child from a hospital or physician at my

expense.
I understand I will be notified first if at all possible.


Physicians
Name:_________________________________________ Phone # _______________________

Name
of Insurance Company:________________________________ Policy #_______________________


Policy holder name:________________________________________


Safety is our top priority! Unless you indicate below, no child will be released from the program without the
signature of a parent/guardian or the signature of one of the individuals listed below (must be at least 16 years
of age):

Name______________________________________Phone_____________________Relationship_______________

Name______________________________________Phone_____________________Relationship_______________

Name______________________________________Phone_____________________Relationship_______________


Does your child have permission to sign him/herself out from ONWARD! programs prior to 5:00 pm? qYes qNo

Does your child have permission to walk home after ONWARD! programs? qYes qNo
**If yes, your child must have permission to sign him/herself out.

I understand photographs or videos may be taken for publicity purposes. I give permission for my childs image to be
used. qYes qNo

I understand some of the programs are off school grounds. I give permission for my child to leave school grounds and
be transported if necessary. I will receive prior notice of any such off school plans (such notice may include brochures,
course schedule, sign-up sheet, special permission slip, etc.) qYes qNo

I give permission for surveys to be given to my child and his/her family for purposes of program development and
evaluation. qYes qNo

I hereby give permission for my child to participate in ONWARD! activities. I assume all risks and hazards, incidental to
such participation, including transportation to and from activity, and I hereby waive, release, absolve, indemnify, and
agree to hold harmless ONWARD!, Orange North Supervisory Union, Orange Center School, Washington Village School,
Williamstown Elementary School, and Williamstown Middle High School, their officers, agents, officials, employees and
volunteers, the organizers, sponsors, supervisors and participants for any claim arising out of an injury to my child. I
will notify ONWARD! if any information about my child changes during the year.

Signature of Parent or Guardian:_____________________________________________ Date ________________
Rev 09.06.11