Emergency After-Care Permission Form

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AVA requests that all parents complete this form at the beginning of each school year. In the event that you are unable to pick up your student(s) after school, your student(s) will be sent to BASE (Before and After School Enrichment) until you arrive. There is a $25 cost to attend BASE as an unscheduled drop in.

Email *

Family Last Name *

Student(s) Name(s) and Grade(s) - please list all AVA student(s) in your family. *

I give permission for the student(s) listed above to participate in the AVA BASE program in the event that I am unable to pick them up at the end of the school day.

Yes

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The student(s) listed above are able to participate in all activities except for those listed below. Please enter "none" if there are no restrictions. *

I also give my consent for emergency medial and surgical treatment in a licensed medical facility by a licensed physician should my child's condition require it in my absence. I understand that in such a case, reasonable attempts would first be made to contact me, time and conditions permitting. I also confirm to the Douglas County School District that my child(ren) listed above is in good health and that his/her participation does not pose a hazard to his/her health or that of participating students. *

Yes

As long as the medical or surgical treatment considered necessary in the situation is in accordance with generally accepted standards of medical practice for the particular type of injury or illness involved, I impose no specific prohibitions regarding treatment unless stated here. *

My child(ren) listed above has the following medical condition(s) which may require emergency care (include allergies). Please list for each child. Enter "none" if there are no conditions. *

Your Name *

Your phone *

By typing my name above and then checking the box below, I am electronically signing this agreement. *

Click here to verify that this is your electronic signature

Required

A copy of your responses will be emailed to the address you provided.

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