Please fill out a form for each participant.  If there are 2 students who will be attending The Zone, you will fill out 2 of these forms.  By filling out this form, you acknowledge:  

(Must be filled in by Parent/Guardian for student participants 18 and under)

You hereby give permission for the participant(s) listed below and on the reverse side to take part in Zone activities, which may include off-site events, academic assistance, continuing education, and recreational programs. If a medical emergency arises, program staff will take all steps necessary to ensure the safety of the participant and will call, if necessary, a public emergency vehicle for transport to an emergency facility. You understand that you will be responsible for any transportation charges and medical expenses incurred.

You further give your consent to the school district and The Zone staff to share the participant’s student records with each other for purposes of providing educational support and assistance. In addition, I understand that school district and / or The Zone will use participant records to evaluate individual progress and improvement, as well as to evaluate the impact of the program on student achievement and to obtain continued funding for the program.

You also acknowledge that the student is expected to abide by the rules of Millsap ISD at all times. A verbal warning will be issued followed by a phone call if behavior continues. Continued behavioral referrals will result in dismissal from the program. Fighting, physical altercation, or inappropriate sexual behavior will result in immediate dismissal.

You further acknowledge that neither the program nor its employees and volunteers are responsible or liable for any personal property loss or bodily injuries incurred during or in connection with any program activities.