Cordova Children's After School Program 2024

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Address: 65 3rd Avenue Cordova, AL. 35550
Contact us at (205)483-9266 if you have any questions

Date *

YYYY

Child's Name *

Date of Birth *

YYYY

Grade Entering Fall 2024 *

Home Address *

Please list any specific academic areas in which your child struggles. We will assist with these skills when time allows *

Reading Level

Allergies, if any

Medical Conditions, if any

Parent/Guardian Name

Address

Phone Number

Secondary Phone Number

Email (Your invoice will be sent to this email)

Secondary Email

List 3 individuals who have permission to pick up your child. Please include their relationship to the child and their phone number

I give permission for child to participate in the Cordova Children's After School Program. I understand that the City of Cordova nor Cordova Economic & Industrial Development Authority assumes no responsibility for injuries or illness as a result of his/her participation in the program athletic activities, sports programs, the use of any equipment, exercise or other activities. I acknowledge that I, parent/guardian, assume the risk for any and all injuries or illnesses, which may result from his/her participation in the After School Program. I hereby release, acquit, discharge and hold harmless, the City of Cordova, CEIDA, servants, or employees from any and all claims, actions, rights, damages or compensation whatsoever, which said parent/guardian or child now have or may hereafter accrue an account of or growing out of any injury or death suffered by said child arising out of or growing out of participation in any program offered by the City of Cordova or CEIDA.

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