Child Information & Permission Form

VFL RISE AFTERSCHOOL PROGRAM

Parent/Guardian Information Form. Please complete this form clearly. All information will be kept confidential and used for the safety and well-being of your child.

Child's Full Name:

Date of Birth:

Grade Level:

Parent/Guardian Full Name:

Relationship to Child:

Home Address With Unit Number

Apt, suite, etc.

Country

City

State

Zip code

Phone Number:

Email Address:

Emergency Contact Name:

Emergency Contact Phone:

Does your child have permission to walk home alone?

Yes

Do you give medical consent in case of an emergency?

Yes

Parent/Guardian Signature

Reset Signature

Date

Captcha *

reCAPTCHA is required.

Afterschool Registration

VFL RISE AFTERSCHOOL PROGRAM