LEAP Fall 2023 Afterschool Registration and Emergency Form
This form must be fully completed by each registered student or the student will not be enrolled. For questions and concerns please contact us via email @ LeapforLeal@gmail.com

You may notice some redundancy in the form fields, however, since we are working with a variety of outside organizations, its critical we capture enough information to ensure your child(ren)'s  record is complete on our system.  Thank you!
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Email *
Student's Name *
Student's Birthdate *
MM
/
DD
/
YYYY
Student's Current Grade *
Teacher's Name *
Parent/Guardian Name *
Primary Phone *
Does your Child go to Extended Day Care? *
Required
What class did you register your child?
Do you give permission for your child/children to walk home? *
Required
By enrolling my child in the LEAP afterschool program, we agree to the protocols and guidance of Leal Elementary and ABC School District, including but not limited to COVID-19 protocols and guidance.  *
Required
By enrolling my child in the LEAP afterschool program, parents understands and agrees that we may acquire photos, video, and audio of your child and use said media of your child without compensation. No names will be attached to the use of media without permission.  *
Required
I understand if my child is not picked up be the time indicated on the enrollment form/class description, a late pickup fee of $10.00 per 5 minutes accrues after a 10 minute grace period.  You will have to pay the late fee before your child attends the next class on the schedule.

I understand that outside organizations may have their own late fee policies.
 *
Required
Health Information: Within the past school year, has your child had any serious injuries, illnesses or surgeries? *
If you answered YES to the above question, please descibe the, injury, illness or surgery
Name of MEDICATIONS to which your child is ALLERGIC (if any, Answer None if applicable): *
My child has SPECIAL HEALTH NEEDS the staff should be aware and/or needs MEDICATION at school. *
 If you answered YES in the above question, please describe your child's special need.
My child has medication on file at LEAL *
Authorization for release of child: If I am unable to be reached in a emergency please call the following caregiver; Please state the person's Name, Relation to child and phone number. *
In the event that I cannot be contacted in the case of an illness or injury, I hereby consent to whatever x-ray, examination, anesthetic, medical dental or surgical diagnosis and/or treatment and hospital care from a license physician and/or surgeon as deemed necessary for my child's safety and welfare.  It is understood that resulting expenses will be my responsibility.  I further understand that it is the responsibility of the Leal Education Arts Program (LEAP) to exercise due care and judgement in summoning medical attention, and I agree to hold LEAP, its officers, employees and agents harmless from any and all liability and claims arising out of any emergency medical treatment which may be deemed necessary should LEAP not be able to contact me. *
Additional Notes for LEAP
Parent Signature (type in full name for signature) *
A copy of your responses will be emailed to the address you provided.
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