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After School Activity Release Form 2021-2022
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* Indicates required question
Email Address
*
Your answer
Student Last Name
*
Your answer
Student First Name
*
Your answer
Parent Phone Number
*
Your answer
Medical Information
*
My child requires an EpiPen and has one in the clinic. I give permission for a club moderator or school employee to access the medication from the clinic, understanding that it will take time to access the medication, in case of an emergency.
My child requires an inhaler and has one in the clinic. I give permission for a club moderator or school employee to access the medication from the clinic, understanding that it will take time to access the medications, in case of an emergency.
I will provide a labeled medication and a completed medication form directly to teacher of the After School Program, discussing the medication use and providing training, if needed.
Does not apply
Club Information
*
Please check all that apply
Frisbee 6th-8th
Frisbee 2nd-5th
Chess Club
PSA Sports
Boxing Club
Required
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