After-School Clubs
PERMISSION SLIP AND EMERGENCY PROCEDURES
Student Name_________________ Home Phone #_________ Grade
______
Address____________________ City__________________ ZIP________
Parent/Guardian Name____________ Work Number_______ Cell #________
E-MAIL _________________
In case of accident or illness, whom may we call if we cannot reach you?
Contact Name______________ Phone #________ Other
__________
THERE WILL NOT BE A REGISTRATION FEE THIS YEAR
Parent/Guardian Signature______________________ Date___________
In the event of a medical emergency, and the parents/guardians cannot be
reached, does the program have your permission to call the City of Rockland 911
emergency number? Yes______ No______
Emergency Transportation: There may be circumstances in which your child may
need to be transported home by personal vehicle. Your signature indicates your
approval of this emergency transportation: Signature___________________________
Does your child have any allergies or physical problems the program should be
aware of? _______________________________________
Special Needs: If you believe your son or daughter needs special accommodations
to be successful in the program, please submit this in
writing and we will be happy to discuss this with you.
______________________________________________________________
If students are not taking the After School Club bus, Parents are responsible
for directing their son or daughter to either walk
home or be picked up within 10 minutes of the end of the club.
Students MUST LEAVE RDMS THROUGH THE DOUBLE DOORS BY THE GYM. (NOT THE FRONT
DOORS).
We are documenting the history of the program for the purposes of fundraising
and publicity. This documentation may include taking and
using photographs of the students in their club activities. If you prefer that
your son or daughter not be photographed, please contact us.
IF YOU HAVE ANY QUESTIONS, PLEASE CALL 596-2020 or 975-5495
OR E-MAIL MRS. CURTIN lcurtin@msad5.org
Your student may pick up their acceptance letter Friday, telling him/her which
club(s) he/she will be in, room numbers, and other details. Please see Mrs.
Curtin by the gym.