STRIBLING AFTERSCHOOL PROGRAM

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					                                Burleson ISD After School Program
                                  Enrollment Form ~ 2011-2012

Please read the front and back carefully and fill in every blank. An enrollment fee of $40
per child must accompany this enrollment form. The enrollment fee is non-refundable.

Student Information
Name _____________________________Start Date ________Campus_________ Teacher ________ Grade _____
Address ____________________________ City _____________ State _____Zip _________Phone # ___________
How many days will they be attending the Burleson ISD After School Program? ______         M T W TH F
Student lives with: (Check all that apply) __Both Parents __Mother __Father __Grandparents __Other _________


Custodial Parent/Guardian Information (This is the first contact for student info)
Full Name ______________________Home # _________________ Cell # _____________ E-mail_____________
Employer _________________________________Work #________________Relationship to Student __________


Spouse of Custodial Parent/Guardian Information (If applicable)
Full Name ______________________ Home # _________________ Cell # _____________E-mail _____________
Employer _________________________________ Work # _______________Relationship to Student __________


Joint Custodial Parent/Guardian Information (If applicable)
Full Name ______________________Home # _________________ Cell # _____________ E-mail_____________
Employer _________________________________ Work # ______________Relationship to Student____________


Spouse of Joint Custodial Parent/Guardian Information (If applicable)
Full Name ______________________Home # _________________ Cell # _______________ E-mail ___________
Employer __________________________________ Work # _____________Relationship to Student ___________


Alternate Contacts/Persons Authorized to Pick Up Your Child
The following persons are authorized to pick up my child in case of sudden illness or accident and the above listed
family cannot be contacted:
1. _____________________________________ Relationship ___________________ Phone # ________________
2. _____________________________________ Relationship ___________________ Phone # ________________
3. _____________________________________ Relationship ___________________ Phone # ________________


Payment Method      The payment method may not be changed after enrollment begins. Please circle one:
Monthly ($1314 total per year)               Weekly ($1460 total per year)                 Drop In ($15 per day)


Please read the Policies and Procedures pages before signing this agreement. By signing this form, I
understand and agree to abide by the Burleson ISD After School Program Policies and Procedures.
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___________________________________________________________________________________________
             Signature of Parent or Guardian                                Date
                                Burleson ISD After School Program
                                  Enrollment Form ~ 2011-2012
                                             Permission Slip and Release

I hereby certify that my son/daughter, _________________________________, has my permission to
participate in the following activity: Burleson ISD After School Program.

I hereby waive and release all claims against the Burleson Independent School District, its Trustees, employees,
volunteers or other representatives. I understand that Burleson I.S.D. does not waive governmental immunity, nor
do its Trustees, employees, or volunteers waive official, professional, or volunteer immunity. I agree to indemnify
the District, its Trustees, employees, volunteers or other representatives and hold them harmless from any claim for
any injury or sickness, for any loss or damage to property that may be suffered by or occur to my son/daughter, or
for any damages caused by my son/daughter during the activity or while traveling to and from the activity.

If, in the judgment of any school district representative, my son/daughter should need immediate care or treatment as
a result of any injury or sickness and I cannot be contacted, I do hereby request, authorize, and consent to such care
and treatment as may be given and do hereby agree to indemnify and save harmless the school district and any
school representative from the claim of any person whomsoever on account of such care and treatment of my
son/daughter.

My student has assured me that his/her conduct and dress will follow the guidelines of the Student Code of Conduct
and any special rules that may be imposed especially for this activity. If there is a violation of conduct, dress code,
or other rules, I understand that my student will be subject to discipline including without limitation, being sent
home by the sponsor at no expense to the school or the sponsor.

Student’s Full Name ______________________________________________ Birth Date ___/___/___ Gender ____

Address ______________________________________________ City ________________________ Zip ________

Parent or Legal Guardian ____________________________________________ Day Phone # _________________

Alternate Contact Person ____________________________________________ Day Phone # _________________

Family Physician ______________________________________________________ Phone # _________________

Hospital preference if conditions so indicate: _________________________________________________________

Authorization for Doctor’s care: Yes _________ No _________

Health Insurance Co. _____________________________________________ Policy # _______________________

Circle if applicable: ADD / ADHD         Asthma       Cardiac     Diabetes      Seizures

Does student have any special health problems? Yes _____ No _____ If “Yes” please list: ___________________

Does student have any allergies? Yes _____ No _____ If “Yes” please list: _______________________________

Is student taking any medication? Yes _____ No _____ If “Yes” please list: _______________________________

The Burleson ISD After School Program staff does not have access to medications in the nurse’s office. If a
prescription medication such as an inhaler must be given, the parent must provide the ASP with that medication
even if the nurse already has it in her office. A medication form with a physician’s signature must be completed and
turned in to the ASP office. The After School Program will strictly enforce BISD medication policies.


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___________________________________________________________________________________________
             Signature of Parent or Guardian                                Date

				
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