PATHFINDERS After School Program - Warrior Run School District
CSIU 21st Century Community Learning Center
Student Registration & Emergency Information
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Name *
Birthday *
MM
/
DD
/
YYYY
Age *
Parents or Legal Guardian(s) Name *
Phone Number (home and/or cell) *
Parent Email  None listed *
Current School Attending *
Free/reduced lunch eligible *
Current Grade   *
Home Address   *
Transportation *
School day, regular, bus stop (N/A if parent pick up) *
In case of emergency, illness, or accident to the student above, list 3 relatives or friends who will assume temporary care and responsibility of your child if you cannot be reached. Please list Name, Relationship to child, and Phone number. PATHFINDERS is authorized to proceed as indicated below:
Emergency contact #1   *
Emergency contact #2 *
Emergency contact #3 *
PATHFINDERS does not have nurses on staff and cannot administer medications. In case of an emergency, please indicate medications student currently has prescribed, along with the reason(s) for the medications and any other medical conditions. (For example, diabetes, asthma, allergies, etc.) *
Allergies: (food, bee stings, poison, etc.) *
Dietary restrictions *
I grant permission for my child to participate in the CSIU/PATHFINDERS activities which may include swimming and physical activities. I release PATHFINDERS from any responsibility for personal property or injury occurring while my child is participating in this program. I grant permission for my child to be photographed for student files/publications/promotions. I have read and agree to follow the school district discipline policy which reflects the consequences for inappropriate behavior. *
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