Middle School Writers' Society - Jan-March 2024

Mondays 4:45-5:45 pm | January 22nd  - March 25th

At the Peterborough Town Library | For people in 6th-8th grade (Feb 19th meeting at Avenue A in Antrim)

Join us for fun creative writing activities, snacks, & the company of other writers! Are you writing a story? Poem? Song? Rap? Come share it with us! SMS students can take the bus from school to the library.

Email *
First and Last Name (nickname) of participant *
Date of Birth of Participant *
MM
/
DD
/
YYYY
Town of residence *
School Name or Homeschool *
Grade *
Does your child have and medical conditions or allergies? If so, please contact Kim Bylancik at 603-831-9958. *
Parent/Guardian name and phone number *
Emergency Contact - phone/text  *
Who else can pick up your child?  Please include phone/text contact information.
ACKNOWLEDGEMENT OF PERSONAL LIABILITY AND WAIVER -- My child has permission to participate in the Avenue A Middle School Writing Society under the supervision of Avenue A Staff and volunteers on  Mondays from 4:45-5:45, January 22nd through March 25th. (No meeting Monday, February 26th).   I understand that this program may expose my child to some risks and I assume any such risk that may arise there from.  I accept full responsibility for all medical expenses for any injuries that might occur to my child by reason of their participation.  By signing this form, I release The Grapevine and The Avenue A Teen Center, it's employees and volunteers ("released parties") from and against any and all claims, demands, actions, complaints, suits or other forms of liability that any of them may sustain.  I also agree to indemnify and hold harmless the released parties from the released claims, including any and all related costs, attorney fees, liabilities, settlements, and/or judgement.  I confirm that I have carefully read this consent and release, and I agree to its terms knowingly and voluntarily.  I also confirm that I am the parent or legal guardian of the child.  This consent and release has been read and is understood by me.  Please type your signature below.   *
EMERGENCY MEDICAL TREATMENT AUTHORIZATION. I hereby give permission for Avenue A volunteers and staff to provide simple first aid treatments to my child when necessary, and in the event of a more serious illness or injury, I give permission for my child to be transported to a hospital or other emergency medical facility to receive emergency medical treatment. I also authorize ambulance/rescue squad attendants to administer such treatment as is medically necessary, and I authorize licensed health practitioners working in the hospital or emergency medical facility to examine and provide emergency medical treatment to my child if warranted. I understand that I will be contacted by Avenue A/The Grapevine personnel as soon as possible regarding any emergency involving my child. (Please type your signature below)
 *
PHOTOGRAPH RELEASE (OPTIONAL): I give Avenue A/The Grapevine permission to use photos of my child taken during the programs, in press releases, on our websites, and other outreach materials. (Please type your signature below.)
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of The Grapevine. Report Abuse
Google Forms