PCMS PEAK Application 2021-22

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PEAK After School details and policies can be reviewed at https://polkschools.org/after-school/They are also posted at each site and available from the PEAK director.

Student Name *

Grade *

Address

Parent/Guardian name(s) *

Parent/guardians contact numbers *

Any additional parent/guardian contact phone numbers

Please list any allergies your child has:

Please list any illnesses/medical conditions your child has:

Please list the names of anyone who has your permission to pick up your child from After School (in addition to the guardians listed above). Students will not be released to anyone who is not listed below without the written/verbal permission of that child’s legal guardian.

If neither guardian can be reached in an emergency situation, please provide an alternate contact and phone number: *

By signing your name below and submitting this form you agree to all PEAK After School policies and Code of Conduct, which can be found under Policies on the PEAK web page. You also agree that PEAK After School staff may seek medical attention for your child in the result of an emergency. *

You can contact PEAK Director, Linley Foster, with any questions or comments at (828) 894-3051 or lfoster@polkschools.org

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